Classification of Shoulder Pain
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Introduction[edit | edit source]
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 [1]. 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.[2]
Evidence for the conservative management of shoulder pain currently does not support any particular approach. There has been a shift from the pathoanatomical model of diagnosis towards treatment or rehabilitation-oriented subgroups that will inform patient management.[2] 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.[2]
Classification Types[edit | edit source]
Pathoanatomic Model[edit | edit source]
Definition of shoulder conditions and the nomenclature used to describe them is extremely varied, and as a result there have been many attempts at standardizing the use of diagnostic labels utilising classication systems. Traditionally these classification systems or diagnostic categories such as those proposed by Waris et al.[3], Cyriax [4], Neer [5], ViikariJuntura [6], Silverstein [7], McCormack et al. [8], Uhthoff & Sarkar [9], ICD10 [10] and Palmer et al. [11] were all based on a pathoanatomic medical model aimed at identifying the pathologic tissues which was responsible for the shoulder pain[12]. The pathoanatomical model looks to explain the source of the patients presenting signs and symptoms based on the presence of specific structural pathology identified through isolated or combined physical examination, imaging and histopathological analysis.[12]
Diagnostic labels based on tissue-specific pathology fail to accurately classify the patient into subgroups for clinical decision-making and many of these classification systems based on the pathoanatomic model for shoulder pain have been shown to be unreliable resulting in a lack of diagnostic consistency in relation to shoulder pain. [13] Recent research suggests that the pathoanatomic model may not provide a classification systems or diagnostic categories that effectively guide treatment decision making in rehabilitation management of shoulder pain.[2]
Shoulder disorders, classified through a pathoanatomic diagnosis infer that patients with the same tissue pathology form a homogeneous group which guide decisions for treatment and prognosis.[2][12] This form of classification suggests that patients with the same pathology should be managed in the same way, have similar prognoses and that the diagnosis remains static throughout the whole period of their care. It is also suggested that it is this pathology which explains the both the symptoms and impairments (activity limitations and participation restrictions) experienced by the patient and that correcting the pathology will improve the symptoms and impairments.[2][14]
Although the pathoanatomic system of diagnosis may be very appropriate for surgical decision making, it may be inadequate for guiding rehabilitation.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.
Examples of Pathoanatomic Diagnostic Labels in the International Classication of Diseases and Related Health Problems 10th Edition (ICD-10) [10]
- M75.0 Adhesive Capsulitis of the Shoulder (Frozen Shoulder, Periarthritis of the Shoulder)
- M75.1 Rotator Cuff Syndrome (Rotator Cuff or Supraspinatus Tear or Rupture (Complete or Incomplete) not specified as Traumatic, Supraspinatus Syndrome)
- M75.2 Bicipital Tendinitis
- M75.3 Calcific Tendinitis of Shoulder, Calcified Bursa of the Shoulder
- M75.4 Impingement Syndrome of the Shoulder
- M75.5 Bursitis of Shoulder
- M75.8 other Shoulder Lesions
Treatment / Rehabilitation Model[edit | edit source]
Recent evidence suggests a poor relationship between diagnostic pathoanatomic classification and chosen rehabilitation interventions among orthopedic physical therapists.and as such this suggests that clinical decision making based on a clinical diagnosis and use of diagnostic labels arrived at using special orthopaedic tests is flawed.[2][12] In line with this current researchers have suggested classification models based on treatment and rehabilitation subgroups including Hughes et al. [16], Schellingerhout et al. [14], Lewis [17], May [18], McClure and Michener [2].
Conclusion[edit | edit source]
| 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
|
Guides specific rehabilitation intervention
|
| Informs Prognosis | My Inform Prognosis |
Further research is required to develop consensus for a treatment based classification system for managing shoulder pain.
References[edit | edit source]
- ↑ Childs MJ, Fritz JM, Piva SR, Whitman JM. Proposal of a Classification System for Patients with Neck Pain. Journal of Orthopaedic & Sports Physical Therapy. 2004 Nov;34(11):686-700.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 McClure, P. W., & Michener, L. A. (2015). Staged Approach for Rehabilitation Classification: Shoulder Disorders (STAR-Shoulder). Physical Therapy, 95(5), 791–800. http://doi.org/10.2522/ptj.20140156
- ↑ Waris P, Kuorinka I, Kurppa K, et al: Epidemiological screening of occupational neck and upper limb disorders, Scand J Work Environ Health 6(suppl):25–38, 1979
- ↑ Cyriax J: Textbook of Orthopaedic Medicine, ed 8, London, 1982, Baillière Tindall
- ↑ Neer CS: Impingement lesions, Clin Orthop Relat Res 173:70–77, 1983
- ↑ ViikariJuntura E: Neck and upper limb disorders among slaughterhouse workers: an epidemiologic and clinical study, Scand J Work Environ Health 9:283–290, 1983
- ↑ Silverstein BA: The prevalence of upper extremity cumulative trauma disorders in industry (thesis), 1985, The University of Michigan, Occupational Health and Safety
- ↑ McCormack RR, Inman RD, Wells A, et al: Prevelance of tendinitis and related disorders of the upper extremity in a manufacturing workforce, J Rheumatol 19:958–964, 1990
- ↑ Uhthoff HK, Sarkar K: An algorithm for shoulder pain caused by soft tissue disorders, Clin Orthop 254:121–127, 1990
- ↑ 10.0 10.1 WHO (World Health Organization): International Classication of Diseases and Related Health Problems. 10th Revision, 2010. http://apps.who.int/classi cations/ apps/icd/icd10online/ (accessed 31 Nov 2017).
- ↑ Palmer K, WalkerBone K, Linaker C, et al: The Southampton Examination Schedule for the Diagnosis of Musculoskeletal Disorders of the Neck and Upper Limb, Ann Rheum Dis 59:5–11, 2000.
- ↑ 12.0 12.1 12.2 12.3 Newton PA. Management of Shoulder and Shoulder Girdle Disorders. Maitland's Peripheral Manipulation E-Book: Management of Neuromusculoskeletal Disorders. 2013 Aug 27;2:142.
- ↑ Klintberg IH, Cools AM, Holmgren TM, Holzhausen AC, Johansson K, Maenhout AG, Moser JS, Spunton V, Ginn K. Consensus for Physiotherapy for Shoulder Pain. International Orthopaedics. 2015 Apr 1;39(4):715-20.
- ↑ 14.0 14.1 Schellingerhout JM, Verhagen AP, Thomas S, et al: Lack of Uniformity in Diagnostic Labelling of Shoulder Pain: Time for a Different Approach, Man Ther 13:478–483, 2008.
- ↑ McClure PW, Michener LA. Staged Approach for Rehabilitation Classification: Shoulder Disorders (STAR–Shoulder). Physical Therapy. 2015 May 1;95(5):791-800.
- ↑ Hughes PC, Taylor NF, Green RA: Most Clinical Tests Cannot Accurately Diagnose Rotator Cuff Pathology: A Systematic Review, Aust J Physiother 54:159–170, 2008.
- ↑ Lewis JS: Rotator Cuff Tendinopathy / Subacromial Impingement Syndrome: Is it Time for a New Method of Assessment? Br J Sports Med 43:236–241, 259–264, 2009.
- ↑ May S, Chance Larsen K, Littlewood C, et al: Reliability of Physical Examination Tests used in the Assessment of Patients with Shoulder Problems: A Systematic Review, Physiotherapy 96(3):179–190, 2010.
