Shoulder Guideline

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Shoulder Guideline

• Chris Hanna
• Gillian Robb

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Acknowledgements

• ACC
• NZGG
• EPIQ
• Guideline Team

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Guideline Team

• Chairperson Bruce Arroll
• Project Manager Gillian Robb
• Assistant Bridget Kool
• Tim Astley Rob Kofoed
• Craig Ball John Mayhew
• Mia Carroll Robert Moran
• Ra Durie Duncan Reid
• Peter Gendall James Watt
• Chris Hanna

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Outline

• Guideline development process
• Guideline content
• Questions

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Guiding principles

• Consumer-focused outcomes
• Multidisciplinary
• Systematic, transparent, replicable processes
• Use of the best available, graded evidence
• Robust methods of synthesising evidence

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Essential steps

• Identifying evidence-practice gaps
• Scoping and questions
• Literature searching, selection and critical
  appraisal
• Evidence tables
• Recommendations
• Consultation

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Guideline development process



Literature search


Selection criteria



Search strategy


Selection of literature

Guideline structure


Critical appraisal
Questions



Scoping


Development of implementation strategy
Evidence tables

Practice Gaps
Recommendations and draft guideline
Guideline Development







Implementation




GDT sign-off draft




Endorsement

Audit indicators






Consultation
Supporting documents






Consultation feedback

Editorial process




Refine draft guideline
Guideline sign-off


Meetings

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Evidence searching and appraisal

• Based on clinical questions
• Hierarchical searching
• Critical appraisal
• Grading of evidence
• Systematic development of recommendations

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Consensus

• Making summary statements requires the guideline
  team to reach consensus about the evidence
• Considered judgement process
• Evidence always trumps opinion!

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From evidence to recommendations
CONSIDERED JUDGMENT
Validity score?
Consider VOLUME CONSISTENCY APPLICABILITY CLINIC
AL IMPACT
Study A

RECOMMENDATION with GRADE
x
ignore
Study B
Summary evidence statement
Study C

Study D

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Final Stages

• Draft guideline written
• Consultation (AGREE Process)
• Revision
• Sign off
• Editorial process
• Endorsement
• Publication

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Dissemination / Implementation

• Dissemination
• Summary guideline
• Guideline
• Supporting documents
• Implementation
• Awareness campaign
• Education programme
• Evaluation

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Costs - Resources

• Time 12-20 months
• Costs 300,000
• Project management costs
• Meeting costs
• Search and appraisal costs
• Peer review and consultation
• Dissemination and implementation

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Full Clinical Assessment

• Purpose
• Check for red flags
• Check for significant structural damage
• Screen for extrinsic causes
• Try to establish a definitive diagnosis

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Red Flags

• Unexplained deformity of swelling
• Significant weakness
• Suspected malignancy
• Fever / chills / malaise
• Significant sensory / motor deficit
• Pulmonary / vascular compromise

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Significant structural damage

• URGENT REFERRAL
• Displaced / unstable fracture
• Severe dislocation GH, AC, or SC joint
• Failed attempt at reduction of dislocated
  shoulder
• Massive tear rotator cuff
• Undiagnosed severe shoulder pain

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Screen for Extrinsic Causes

• Cervical spine
• Nerve disorders
• Inflammatory disorders
• Complex Regional Pain Syndrome
• Myofascial pain syndrome
• Scapulo-thoracic articulation
• Thoracic and rib injuries
• Visceral disorders

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Diagnosis

• Rotator cuff
• Frozen shoulder
• Instabilities
• AC joint
• SC joint

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Rotator Cuff Disorders

• Key points
• Most common
• Rare before the age of 35
• Continuum mild strain --- massive tear
• Full thickness tears in the elderly can be
  compatible with normal painless function

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Rotator cuff Diagnosis

• Age gt 35
• Upper arm pain / night pain
• Painful arc
• Limited active range
• Full passive range
• Possible weakness
• ve impingement sign

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Rotator Cuff Investigations

• Diagnostic Ultrasound
• Indications Suspected significant rotator cuff
  damage
• No studies in primary care setting
• Valid for the diagnosis of full thickness tears
  (LRve 13.16 9.13-18.95)
• No conclusive evidence that it is valid for
  partial thickness tears.

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Rotator Cuff Management

• Analgesics / NSAIDS
• Subacromial corticosteroid injection
• Supervised exercise
• Early repair for full thickness tears

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Related disorders

• Biceps tendinosis
• Calcific tendonitis
• Isolated muscle tears
• Subscapularis
• Pec major

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Frozen shoulder

• Key Points
• Women 40-60 years of age
• Gradual and spontaneous onset of pain
• Global restriction of GH joint movement
• Three stages
• Lengthy recovery (patient expectations!)

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Frozen shoulder Diagnosis

• Limited active and passive range of movement
• Increasing severity of pain
• Significant functional limitation
• X-rays / blood work not indicated

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Frozen shoulder Management

• Intra-articular corticosteroid injection
• Laser therapy
• Acupuncture plus exercise
• Exercise

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Instability disorders

• Includes
• Acute first time dislocation
• Recurrent dislocation
• Multidirectional instability
• Labral injuries

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Acute first time dislocation

• Key Points
• Trauma involved
• Males gt females
• Young and active

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Acute dislocation Diagnosis

• Typically
• Pain / muscle spasm
• Empty space below acromion
• Diagnostic value of radiography not clear
• Assess and document neurovascular function

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Acute dislocation Initial Management

• Use of x-ray (pre and post reduction)
• Reduction (appropriate expertise required)
• Attempt reduction (not gt two attempts!)
• Provide adequate analgesia
• Avoid excessive force

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Acute dislocationPost-reduction management

• Non-operative
• Sling, analgesia and refer for supervised
  exercise programme
• No evidence for immobilisation (internal vs
  external rotation)
• Limited evidence to support primary surgical
  repair in young people engaged in demanding
  physical activity

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Recurrent dislocation

• Manage as for acute first dislocation
• Refer for orthopaedic evaluation after second
  dislocation

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Multidirectional Instability

• Key points
• Global laxity
• Should be evaluated by orthopaedic specialist
• Six month trial of comprehensive rehab programme
  recommended
• Orthopaedic referral if poor response

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Labral Injuries

• Relatively uncommon
• More common in overhead athletes
• Progressive failure of the labrum
• Traumatic event associated with anterior
  dislocation
• Activity related pain / dead arm
• Orthopaedic referral required

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AC joint

• Key points
• Mostly due to fall on point of shoulder
• Graded according to extent of damage
• Grade I Intact
• Grade II Up to 50 subluxation
• Grade III gt 50 subluxation
• Grade III ear tickler / other

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Diagnosis

• Localised pain and tenderness over ACJ
• Prominence over AC joint
• Pain with horizontal adduction
• X-ray
• Some evidence that weighted views not effective

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Management

• Grades I, II III
• Non-operative management
• Refer for orthopaedic assessment if poor response
  after 3 months
• Grade III
• Refer for orthopaedic evaluation

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Osteolysis

• Definition
• Key features
• Management

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SC joint

• Relatively uncommon
• Mostly mild injury responding to non-operative
  management
• Severe injuries (posterior dislocations) may
  result in pulmonary or vascular compromise