Hello, everyone. Thank you for coming to our webinar about the ACOM Clinical Practice Guidelines Shoulder Disorders. This is the next installment of MD Guidelines Research Briefs. We're very happy to partner with ACOM and our amazing speakers today to learn more about the newly released Shoulder Disorder Guidelines. Just some quick housekeeping. All participants will be muted during the entirety of the webinar. We're going to send out everything at the end, including the slides and handouts and evaluations. If you'd like to ask any questions, we ask that you please use the QA section of Zoom. You can also use the chat just to have features, but we're going to be monitoring the Q&A section for questions to answer at the end of the webinar. These are our speakers today. I'm going to do a short bio on each of them. So Dr. Rachel Kaufman is from Tacoma, Washington. With her PhD in epidemiology, she maintains her double boards in family medicine and occupational medicine from the University of Utah. She has been an occupational medicine physician in Washington State since 2005 with Group Health and Kaiser Permanente. She is the Kaiser Permanente Center for Occupational Health Education Medical Director through a grant from the Washington State Labor and Industries to Kaiser Permanente. Her activities are focused on treating injured workers, occupational medicine best practices, including the reducing of long-term disability. She has contributed to the ACOM guidelines since 2010. Next, we have Dr. Lori Michener. She's in Los Angeles, California. She is a board-certified clinical specialist in sports physical therapy, a professor, and a director of clinical outcomes and research at the Division of Biokinesiology and Physical Therapy, housed at the University of Southern California. She has a PhD from MCP Hanneman University, an M.Ed. from the University of Virginia, and a PT bachelor's from the University at Buffalo. Our next speaker is Ethan Moses. Dr. Moses is the medical director for the Colorado Division of Worker Compensation and the editor of the Colorado Medical Treatment Guidelines. He is an ACOM fellow, where he serves as a member of the Council on Occupational and Environmental Medicine Practice. He sees patients as the chief medical officer at Peak Form Medical Center and holds faculty appointments at both the Colorado School of Public Health and the University of Colorado School of Medicine. Dr. Moses is a former president and board member of the Rocky Mountain Academy of Occupational and Environmental Medicine. He has previously served in several executive leadership positions, including chief of the Division of Occupational Medicine at Denver Health and Hospital Authority, chief resident at the University of Colorado's Occupational Environmental Medicine Residency, and chief of aerospace medicine at Buckley Air Force Base, where he served as an active flight duty surgeon. Our final speaker is Manny Berenji. She's in Long Beach, California, and is the chief of occupational health at the U.S. Department of Veterans Affairs Long Beach Healthcare System, the site director of the University of California Irvine Occupational Environmental Medicine Residency Program, and an OEM physician. She is also an assistant clinical professor at UC Irvine School of Medicine and UC Irvine School of Public Health. She is actively involved in occupational medicine, serving on many national committees within ACOM, including the environmental medicine and health informatics one. She is also a fellow at the American College of Preventative Medicine and involved in the UC Center for Climate Health and Equity as the academic and community partnership lead. Our speakers have no relevant financial relationship, and we're going to go ahead and get started with learning about the shoulder guideline that was recently released. With that, I will hand it over to Dr. Kauffman. Good morning, I'm Dr. Rachel Kaufman, and hopefully you can see me now. Thank you for joining us today. Shoulder disorders, why do we care? Shoulder pain and problems are a common reason for people to visit medical providers as well as a common cause of workplace claims leading to significant costs and suffering. Today I'll be presenting information primarily from the introductory section of the shoulder disorders chapter, where we start with many reasons why we care about the shoulders and the expenses they cause. Specifically in workers' compensation, there are increased costs, slower recovery, as well as risks of poor outcomes. Shoulder problems tend to recur. The information in the foundation sections of the ACOM guidelines can help reduce the human and financial costs and suffering, not just for shoulder disorders, but other disorders as well. And there's a link here for people after the presentation to some of the favorite parts of the guidelines for me. The shoulder chapter covers multiple common disorders, including potentially serious conditions such as fractures, glenohumeral dislocation, infections, and neurological conditions. Specific shoulder disorders, full thickness rotator cuff tears, rotator cuff tendinopathy syndrome such as impingement syndrome, rotator cuff tendinosis, rotator cuff tendinopathy, supraspinatus tendinosis, partial thickness rotator cuff tears, bursitis, bicipital tendinosis, acromioclavicular or AC joint sprains and separations, labral tears, thoracic outlet syndrome, brachial plexus injuries, adhesive capillitis, also called frozen shoulder, calcific tendinitis, and instability. Also nonspecific shoulder disorders that suggest neither internal disarrangement or referred pain including trigger points and myofascial pain, myofascial or muscle tension syndrome, fibromyalgia, which is also covered in the chronic pain guideline, degenerative joint disease such as osteoarthrosis, and nonspecific shoulder pain. It is critical to note that shoulder pain may often be a symptom of another disorder in another body part, especially the cervical spine or thorax. Thus, careful evaluation to determine the diagnosis and origin of the pain is critical in order to be able to form a well-founded evidence-based approach to treatment. For example, see the cervical and thoracic spine disorders guideline. There are lots of different topics covered both in the introduction and more specifically with individual conditions, including such topics as the assessment and diagnosis, red flags, relationship to work, interactions with work, treatment including rehab, imaging, surgery, and never forget in workers' comp, recovery delays. Today we'll present different cases while demonstrating guideline use. We'll highlight useful tools throughout the guidelines as well as red flags and new information in this chapter. We will meet our new patient and start gathering information in a useful manner. These tools are some of my personal favorites in the guidelines, again, examples on your screen as well as links to other chapters. Our history and exam points us to which diagnoses to check for. Table one in the chapter lists information about different shoulder testing. Most of which isn't as good as providers might have assumed when we were trained. Many examination maneuvers have not been validated in quality clinical trials and do not have well-established sensitivities and specificities. Many exam maneuvers are also reportedly nonspecific and are of questionable value. Test utility depends on the context. For example, findings of instability maneuvers are irrelevant if instability is not our patient's problem. If certain shoulder problems, such as pain, are sufficiently severe, other diagnostic tests may not be helpful. For example, in the presence of substantial joint stiffness and capsulitis, impingement maneuvers are completely invalid. Work-relatedness. It's really easy if our patient comes in broken and bleeding. Otherwise, we would need more information. The work-relatedness chapter and work-relatedness sections of this chapter are both helpful in pointing out questions to ask and factors to consider. More and more, genetics changes with aging that are symmetric in spite of one arm being used more significantly than the other. Findings that are incidental but are not pain generators, non-occupational factors, age, gender, underlying conditions such as diabetes, atherosclerosis, have been found to contribute to or cause pain or limited function while people are working or while they happen to be at work. So, our first patient, 35-year-old maintenance worker slips and falls onto an outstretched hand while outside working. The momentum tips the worker hard and bounces on the side of her arm and shoulder. Coworkers see and come over to help her. She has immediate pain and trouble moving her arm at the shoulder. She holds her arm close to her body as if in a sling. Nothing else is hurt. Nothing else hit the ground. In spite of her profound embarrassment and falling in front of everybody, coworkers insist that she be medically evaluated. And we as providers get ready to move through our first algorithm. When I see this patient, I'm concerned about red flags, broken bones, fractures of the humeral head or the humerus, dislocations which can come with fractures, stretch injury, what's the person's gender that can affect things, changes in treatment, neurologically intact, brachial plexus or radial nerve injury, rotator cuff injury, is there a rupture, do I need advanced imaging, surgical considerations, is there a separated shoulder? I need to be cautious about my language even as I do my evaluation. People may not know what a fracture means. Words like rupture can contribute to catastrophic thinking. The absence of red flags largely rules out the need for special studies, referral or inpatient care during the first four to six weeks for most patients, most of which have spontaneous recovery. Some points in the current guidelines, glenohumeral dislocations are considered potentially serious until it is confirmed that there is not a fracture nerve damage. Overall, the younger the person is at the time of initial dislocation, the likelier for re-dislocation. If the shoulder presents in the dislocated position, shoulder films before and after reduction are indicated. Stress films of the AC joint are not typically needed as clinically important, meaning need surgery, separated shoulders are usually obvious on exam. The threshold for obtaining x-rays whenever there is an unusual clinical presentation should be particularly low. Our case got x-rays. The special studies section has recommendations and explanations as to why some imaging is appropriate earlier or later. As many patients will have significant and sufficient improvement in the first weeks only some will need official examination and imaging to confirm or refine the diagnosis, prognosis, surgery or treatment. Factors to consider when whether an MRI or MRI would be useful to guide treatment or when to order. Earlier imaging with MRI is indicated among those with suspected acute tears of the rotator cuff, especially among younger workers and or those with functional deficits. In some cases, an MRI might be acceptable rather than an MR arthrogram. The criteria presented in table three follow the clinical thought process for non-red flag conditions. A big issue for some is whether or not to sling. Slings can cause iatrogenic stiffness and pain. There are some conditions where it's appropriate. Our case does not need it. As I see your patient, I wonder if I need to refer for surgery. I rule out some red flags. Rotator cuff tears appear to occur over the years due to degenerative rotator cuff tendinopathy culminating in a full thickness rotator cuff tear, which can be common over the age of 50, but our patient is only 35. As I look to table one and choose tests useful for examining the supraspinatus, I base on exam findings what to do next. Eventually, I order an MRI. Meanwhile, I got her into rehab to get her going on her recovery. After discussing MRI results with her, I encouraged her to keep her arm active and send her on to a surgeon to discuss surgery. As it happens, good rehab requires good communication amongst treatment team members. The available research consistently supports active exercise therapy, so I send our patient to Dr. Mishner. The key thing with communication with the physician from the physical therapist is understanding what the diagnosis is. As you send a patient to physical therapy, indicating what the diagnosis is, if there's a surgical procedure involved and or planned, but important if it's a surgical procedure, what happened and even the operative note is very helpful to guide rehabilitation. Here I also indicate red and yellow flags and might take a different context of what we may think of those as not appropriate for treatment or red flags of other more sinister things. I say red flags are what not to do and yellow flags precautions. That's important to communicate to the physical therapist so they know right off, listen, don't move their arm, don't do whatever the instruction is. And then essentially evaluate and treat from there is what we need. The treatment should be active exercise therapy, the guidelines indicate, to restore also any range of motion that may have been lost, getting ready for surgery. But they should also be expecting to do exercise at home and what to do if the injured worker is not progressing that communication back to the surgeon and or physician that referred. The reports back should be frequent enough to communicate when there's change in status, but no less than monthly for sure. If the patient is expecting to go to surgery, for example, in a month, even at two weeks, there could be a report back, especially in a workman's compensation population to understand how the patient's doing and on track for ready for pre-op. Is there improvement? So making sure that you clearly articulate what the range of motion looks like, what their function looks like, and any specific patient self-report and performance measures. This helps everyone to get an understanding about what state they're in when they show up for surgery and or their progress. Clearly and concisely, is there progress expected? Is there a lack of progress? Is it slower? And what do you think that's from in order to understand how it should anything be adjusted and communication with the physician. And use of active treatment versus passive modalities should be generally indicated to understand what the treatment generally consists of so they understand if there's not progress and what the improvement is. Last, but not by any sense least, is the return to work. People need to be allowed to do their ADLs as soon as possible because they will do them. Brushing their teeth, changing their infant, petting their cat, putting on their shoes or bra, feeding themselves. There are many additional tools within the MD guidelines to help people return to work, reduce disability, and return to function. Not just pass out of the workers' comp system to the social security disability system. The shoulder chapter is excellent in helping ID shoulder diagnoses and treatment, but if people are not progressing as expected, please turn to these other resources. Now I'll turn the presentation over to Dr. Moses and Dr. Mishner. Thank you, Dr. Kauffman. I'm Dr. Ethan Moses and I'm excited today to share our second case with you on applying the guideline, the case of Mr. Woodward. Now Mr. Woodward is a 55-year-old carpenter who presents to your office with acute left shoulder pain. He was lifting a wooden beam at work when he started to experience shoulder pain and dropped this 30-pound beam onto his shoulder, striking the side of his shoulder. Like Dr. Kauffman showed us in table two, you rule out the red flag signs and symptoms and your exam is most consistent with the shoulder sprain. Based on your clinical exam, you suspect that it's likely a supraspinatus tendinitis with some possible impingement. I just received a chat that the slide is too small. Can you see my slides okay? Yeah, it looks okay. If sometimes people, if you minimize and maximize the zoom, it might help with the slide size. Sounds good. Sorry for the brief interruption there. But because you suspect supraspinatus tendinitis, you appropriately reference the rotator cuff tendinopathies section of the shoulder disorders clinical practice guideline. And because he was struck by this beam, you consider diagnostic imaging. So you take a look at the guideline and say, okay, well, what does the guideline say? You see that according to the guideline, most patients with shoulder pain are candidates for x-rays. So you order an x-ray of the shoulder and you find that the results are essentially unremarkable, save for a type two acromion. You don't really have a significant suspicion of a tear at this point. And so the guidelines help inform you that an early MRI is not really indicated in this case. So you begin to think about your early treatment and you decide to initiate conservative management. Well, the guideline has things to say about that too. And in the general approach to treatment section, you see that a functional assessment of the patient is a very essential part of establishing a function-based treatment strategy. So you conduct that functional assessment and you see that the patient is rather significantly limited in their activities of daily living. You use a functional outcome measure called the quick dash, and that places the patient in a moderately disabled category. You take a look at some of the other recommendations in the guideline about how to start conservative management. And you prescribe ice and heat, non-prescription analgesics like ibuprofen and Tylenol. You establish medically appropriate work restrictions based on your clinical functional assessment. And you see that education begins at the first visit. And so you counsel the patient on the diagnosis, what the prognosis is, and you establish positive expectations for recovery. You also conduct a psychosocial assessment. In this case, you use a standardized and validated psychosocial screening called the PHQ-9 and find that the patient is in the normal category. You also consult the guideline again and see that an exercise prescription with resisted and active exercise is an important part. But you want to know more about how to do that. And so you take a look. My apologies. Let me try to share my screen again. So you take a look at this. The activity modification and exercise section. My apologies for the brief delay there. And because of the patient's functional limitations, you really do feel that a supervised program is needed because of the level of functional loss the patient is demonstrating. So you decide to initiate a referral to physical therapy. And you can see in the guidelines that the initial recommendation for therapy is that it should, the frequency would be one to three sessions a week for up to four weeks. And so you initiate that therapy referral for twice a week for four weeks. And you send that to a trusted local therapist. And at this point, I'd like to hand it over to Dr. Mishner to discuss that referral. So as we discussed with the last case, here, again, Dr. Moses, when he refers, will say, here's my diagnosis. And here is what not to do and precautions. That's the key thing when we're sending, when a referral comes to physical therapy, to understand from what you've seen with the patient already, what not to do and what is precaution. With this patient, there's very little. You want to get them started with active exercise, and we'll talk about that in a second. And also that they will be exercising at home, not just in that two to three days a week that they may be coming into therapy. The frequency may alter when they get to therapy if they are not making great progress and more therapy, more intense therapy in the beginning may be helpful. And so when you send the reports back, just like we talked about earlier as well, that they should be fairly frequent to help the referring physician understand. And then also the functional improvements of what's happening and whether or not they have a lack of progress. And is there any barriers? And again, as we discussed before, in NISPOL, active therapy should be done. So the progress report should briefly also explain from therapy, what is happening in therapy. And making sure that it's consistent with the guidelines and there's active treatment occurring as the predominant component of physical therapy. Thank you so much, Dr. Mishner. So drawing on the shoulder disorders clinical practice guideline, physical therapy starts and the patient makes clear functional progress in several ways that you see. One is your clinical assessment as you continue to follow the patient. There are also clinical measures and improvements in range of motion and strength documented by the physical therapist. You also continue to follow the patient with the quick dash patient reported outcome measure and see gradual improvements, gradual reductions in the disability. And you're able to advance his restrictions. And so you decide that based on this functional progress, you want to see this continue. He's making progress. So you order more physical therapy, but you receive a denial from the carrier. They request documentation of ongoing functional gains. And you're wondering, why are they doing this? So you pull up the guideline again, and you take a look at the rehabilitation program section in the treatment recommendations for rotator cuff tendinopathies. And you see that this supervised program should continue as long as objective functional improvement and symptom reduction is occurring. Because of that excellent communication with your trusted physical therapist, you're able to document this easily and send it back to the insurance carrier quickly, which resolves that denial and the carrier approves additional physical therapy. So PT continues twice weekly. And at this point, Mr. Woodward has had about 12 sessions of PT. He's made significant progress. His restrictions have been liberalized significantly, but he's still retained some work restrictions. And he's having ongoing pain and functional loss. You take a look at all of the documentation that you've received from the physical therapist, as well as your own clinical assessment of his function and the patient reported outcome measure. And you determine that he has really plateaued in his response to active therapeutic exercise. So what do we do now? So you take a look at the guideline again, and you see that the guidelines say that the exercise prescription should be regularly monitored. And if it fails to produce ongoing improvements, then you should either reconsider the diagnosis and or consider a referral for a consultation. So you decide to revisit the diagnosis. You order an MRI as additional diagnostic imaging to determine if there's any underlying pathology that's inhibiting Mr. Woodward's recovery. You consult the guidelines to make sure that this is guideline consistent. And you see that an MRI is strongly recommended to rule out a rotator cuff tear. Simultaneously, you initiate a referral to a trusted orthopedic surgeon who you know will also continue that communication with you, just like your trusted physical therapist. So you go ahead and order that MRI. And so you see, get the report back while they're waiting for an appointment with the orthopedic surgeon. And you see that there is severe tendonitis of the supraspinatus tendon, but no tearing. This confirms your initial clinical diagnosis of supraspinatus pathology. It also shows some moderate subscapularis and infraspinatus tendinosis, again, without tear. There's no significant arthritis, and there's minor fraying of the labrum that appears to be longstanding. And once again, just like on the x-ray, you see that the patient does have a type 2 acromion. And like all good radiology reports, they tell you to correlate this clinically. So you discuss this in detail with Mr. Woodward. You explain that there's not really acute pathology that's demonstrated on this MRI, but rather that this injury has exacerbated an underlying condition. You help him to understand that the shoulder is stable, and you discuss the difference between hurt versus harm, and help him to understand how a gradual increase in activity is likely to help improve his symptoms. And so he moves on to see orthopedics, and the orthopedic surgeon gives you a call, and she tells you that they're planning for an injection. But does let you know that surgery may be an option based on what they saw on the MRI. In this case, they might be considering a subacromial decompression. So they call you primarily to discuss this planned injection, and let you know that they're planning on doing a subacromial steroid injection. Of course, you recognize this is standard practice, because it's both diagnostic and therapeutic, or can be therapeutic. But you remember the recent update to the shoulder disorders clinical practice guidelines, so you decide to take a closer look. And you see that steroid injections are still moderately recommended. But you note that there is a new caution there about surgery, where it says that a steroid injection can double the risk for infection following surgery, and that risk carries forward, especially within the first six months after the injection. And so because you realize that surgery is a possible next step, you dig a little deeper, and you find a new recommendation for subacromial catarrh lac. You see that it's evidence level B, and it's moderately recommended, just like corticosteroids. And so with the help of the guideline, you educate your orthopedic surgeon colleague about the subacromial catarrh lac injections, because multiple trials suggest equivalence with corticosteroids, but it does not have the same adverse effects on increasing the risk for infection post-surgery. So armed with that discussion, the patient does receive an injection. The anesthetic-effective portion of the injection was positive for a diagnostic response, so you are in the right place. But unfortunately, there was no lasting relief or improvement in the patient's function. The patient returns to your office and is clearly struggling. They become tearful in the office with you, sharing how the injury at work has affected their life at home and at work. And you redo that psychosocial screening with the PHQ-9. This time, it shows that the patient is at risk of depression. Obviously, at this point in the case, you're concerned for chronic pain, because we're approaching that three-month mark. And so you decide to consult the chronic pain clinical practice guideline. Based on the recommendations you find there, you see that a referral for psychological evaluation and treatment is guideline consistent. And so you refer Mr. Woodward to a local health psychologist who does an evaluation and determines that cognitive behavioral therapy would be helpful for him. And so psychotherapeutic services start to help mitigate some of the stressors from this work injury. In the meantime, the surgeon calls you back. They saw a webinar on PRP and gave you a call, because they think that this Mr. Woodward might be a candidate for PRP, because they're considering a subacromial decompression. And the surgeon thinks that PRP might help forestall or even prevent surgery. But recognizing that you're the expert in occupational medicine, they kind of wanted to run it by you to see if you would back them up with the carrier. And so what do you say? Well, first we want to take a look at what is PRP. Well, PRP stands for platelet-rich plasma. It's an injection of the patient's own platelets into the site of tissue degeneration or damage. What happens is they draw one or a few tubes of blood, they spin it down in centrifuge, they draw up the Buffy code, and they inject the platelets back into the site of damage or degeneration. This is believed to induce the release of growth factors, including IGF, TGF-beta, VEGF, and platelet-derived growth factor. It's believed to stimulate healing at the site, whether the symptoms are due to damage or just degeneration due to age. And so thinking back to this webinar, you say, huh, I remember mentioning something about that. And so what does the guideline say? Well, you can see here that there's currently no recommendation for or against subacromial platelet-rich plasma. The reason for this is that the studies are very mixed, including systematic reviews and meta-analyses, which have reported conflicting results. As a result, the clinical practice guidelines panel, when discussing this, ended up in a split vote. The majority agreed with a no-recommended stance, 8% agreed with recommended, and roughly 33% agreed with not recommended. And so you can see that with this information, there's still a lot of uncertainty out there about the usefulness of platelet-rich plasma injections for shoulder disorders. And so you share this with the orthopedic surgeon, and the orthopedic surgeon recognizes this and requests authorization for an ultrasound-guided PRP injection because they feel like it might be useful here. The insurance carrier, being similarly uncertain, requests the opinion of a utilization review physician who considers it and recognizes that it might be useful to foresaw a subacromial decompression, but it's costly. And so the carrier ultimately denies the request. The surgeon accepts this and says, well, we'll begin planning for the subacromial decompression then. And you just go back to the guideline, make sure your knowledge is still intact, and you see that the guideline recommendation for subacromial decompression is unchanged. And the patient is a candidate because they've got shoulder pain, they have impaired function, they've got an MRI confirming the physical exam findings, and they did respond positively to the diagnostic portion of the injection. So you sit down with the patient and you discuss it. But Mr. Woodward is pretty uncertain about surgery. He tells you that the psychotherapeutic services and the cognitive behavioral therapy have really helped him to realize that the domain of pain is mainly in the brain. And it's really helped him to mitigate the psychosocial stressors from this work injury. He also tells you that your discussion of the MRI really helped him. Recognizing that there was no acute pathology, he felt enabled to work harder on the shoulder. And your discussion about the difference between hurt and harm really helped him to feel confident in his recovery. So he feels now that if he's given a little more time, he may be able to recover without surgery because he's been gradually increasing his activities at home and feels that he can do more. And so your clinical exam shows that some significant improvements. And so you decide to continue to help him advance his home exercise and strengthening and gradually increase his ability to do activities at work in a gradated fashion. Over the next four weeks, you increase his activity level and you see gradual functional improvement in your clinical assessments and on the patient reported outcome measures. Four weeks later, he feels ready to initiate a trial at full duty. This was successful. He tolerates it with only some minor self-modifications. With his return to work, the psychosocial stressors that he was encountering improved and with it, his recovery improves as well. He gains confidence in that recovery. And eventually he reaches MMI with only mild residuals with some pain with certain activities, which he's able to mitigate with his own self-directed modifications, both at work and at home. And with that, I'd like to turn it over to Dr. Baringi for our third case. Great. Thank you so much, Dr. Moses. So we're going to actually have a little bit of fun for the last couple of minutes of this webinar. We're actually going to do a live demo. So just bear with me for one second as I share my screen. All right, folks, can you all see that? Yes, that is a yes. Thank you. So really my purpose today is to provide some tutorial about how to use the guidelines. The guidelines are very approachable, very user friendly. I use this in my clinical practice all the time and really trying to encourage as many of you as possible to really get familiar with the guidelines and how to use this interface in your practices. I wanted to actually present a case and then hopefully be able to weave in the live demo as I go through the case. And we definitely want to have time for questions. So we'll be mindful of time. So let me go ahead and give you all a brief overview of my case. So I have Mrs. Martinez. She's a 60-year-old female. She's right hand dominant. She works as an administrative assistant at an insurance company on site. She's been working in this occupation for about 10 years. No previous history of work injuries. So it turns out that she was at work. She was trying to open the door. She used her right shoulder to kind of bump the door forward. And she started to notice pain in her right shoulder. Just in terms of past medical history, she does have a history of hypertension, diabetes mellitus type 2. And she also has had a previous motor vehicle accident where she sustained a proximal humeral fracture, but it healed without surgery. She's a smoker. She's been smoking for over 20 plus years, about a pack per day on average. And she does have a family history of osteoarthritis as well as connective tissue disorder. So let's go ahead and jump right in, folks. Let's go ahead and click on shoulder disorders. And where I really like to start off with is looking at the workflows. For a lot of us, we want to be able to map out how we're going to go about, first of all, diagnosing this patient. And I always like to start off with the master algorithm. So really looking at this and identifying first and foremost, does this patient have any red flags? So you do the examination. You find that she has no erythema, no bruising, no signs of any atrophy. There's no signs of any scapular winging. She does have noted tenderness to palpation along the long head of the biceps tendon. She also has noted tenderness to palpation along the subacromial bursa as well as along the rotator cuff muscle insertions. You do the full exam, including the passive and active range of motion maneuvers. So passively, she is looking okay. And I always recommend folks to do the passive range of motion assessment with the patient supine. And then you do the active range of motion and you do find that she has noted deficits with forward flexion, external rotation, and abduction. You do the provocative maneuvers and you find that she does have signs that demonstrate some impingement. And she has five minus out of five right bicep, deltoid, and tricep strength. So let's take a look here. So we want to be able to focus on the initial visit, since this is where the patient is first coming in. And you really want to be able to kind of figure out where this person is. Should we get an x-ray? Do we need to do further diagnostic imaging? In this case, the patient is complaining of a bit of pain in that area, but it's really up to you, the provider, to make that determination. As we had seen with Dr. Moses's case, many times x-rays are indicated. But in this case, an x-ray is not indicated at the first presentation because there wasn't any severe trauma to the right shoulder that would indicate the need for imaging, at least at this point in time. So you go ahead and follow the prompts. Let's go ahead and take a look at algorithm one. So we're focusing on the initial evaluation. We already ruled out any red flags, and we want to be able to provide an assessment. Let's go ahead and look at algorithm two. So in this case, this patient was diagnosed with a right shoulder contusion. She had a bump, very minimal force, and we want to be able to provide an assessment for this patient and give her reassurance that she will get better in a couple of weeks. We want to make sure that she's given an NSAID, but we have to take into account that she does have underlying hypertension. So we want to give her an NSAID that's not going to cause further problems with that. In this case, I would recommend naproxen at a lower dose. We want to make sure that we're giving her instructions about exercise, home exercise program, as well as a physical therapy referral that can help speed up her recovery. We have to take into account many of these factors, including the fact that she is 60 years old. She wants to be able to continue to work, and we want to make sure that she's able to have a timely return to work outcome. So you go ahead and do these things for her, and then you have her come back and see you in a couple of weeks. So let's take a look at that part of the guideline. So what I really love about MD guidelines and how these algorithms are set up is that you can actually go initial visit, and then you can actually go to the follow-up visit. So if you actually go back to algorithm two and you scroll down, you can actually look at what you need to do at the two to four week mark. And you can ask Ms. Martinez, hi Ms. Martinez, how are you doing? At the two to four week mark. And you can ask Ms. Martinez, hi Ms. Martinez, have you had any changes in your symptoms? And she tells you that she really has not. She actually feels that the pain has gotten worse. She tells you that the pain is now a five to eight out of 10. It's worse in the morning, but it does get better over the course of the day. And she has made a little progress with physical therapy. She's had six sessions thus far, but continues to have ongoing right shoulder pain that's not completely resolved. So what do you do now? So you really have to take into account the patient centric factors. So she's 60 years old. She does have a family history of osteoarthritis, as well as a rheumatological disease, mixed tissue connective disorder. So in this case, I would recommend getting an X-ray just to see what's going on with her shoulder. And as you remember, she actually did have previous trauma to the right shoulder. So it's really important to gauge where her right shoulder is at this current time, given the fact that she hasn't been making a lot of significant progress with her physical therapy and home exercise regimen. So going back to the guideline, I'm telling you, these algorithms are super helpful because it really helps you map out your patient's progress. And you can look at folks who are slow to recover. Let's take a look at algorithm three. So we have a patient who has a couple of comorbid factors, and she's having a bit of what we can already identify as a delay with getting her back to full duty work. So we want to be able to follow these algorithms and be able to kind of apply it to our real patient in real time. It may not be perfectly applicable in every single case, but we can take the lessons learned from these algorithms, from all the evidence that's been accumulated over the past couple of decades, to really formalize a treatment plan that's going to work for our patient. So in this case, we realize that she does continue to have noted deficits with active range of motion. And she's also having no signs of shoulder laxity, which is a good thing. So let's go ahead and go to algorithm five. So I know this can be a bit overwhelming at times in terms of following the prompts and being able to know where to go at what point in time, but really use your clinical intuition. You really want to use this guideline as a really like a helping hand to help you navigate the patient's course and making sure that the patient is getting the appropriate treatment at the appropriate time. So in this case, you realize that you get the x-ray. She actually has evidence of glenohumeral osteoarthritis. There's no issues with the trauma that she sustained with the motor vehicle accident a number of years back. And you want to be able to give her a formalized treatment plan, taking into account her underlying osteoarthritis. So really at the end of the day, you have to take your patient's information, how the patient is progressing through the treatment course, and making sure that you're using the guideline to help you make those decisions using evidence-based medicine. And with that, I will go ahead and hand it off to Carrie. All right. Thank you, everyone, so much for your great presentations. If anybody has questions, go ahead and place them in the chat, and we will try to get to some of your questions. I do see that people were typing things in and being answered at the time. As a moderator, I guess I'll start with one question. This was a rewrite of the ACOM guideline, so new evidence. Was there anything that was especially surprising that you guys found? And Manny, you can stop sharing your screen, and I can start sharing. For me, a couple of different things. One was that the MRA, I was taught that you use MRAs if you are worried about a labral tear. And in fact, one of the things that came up actually down to the wire in the final edits was there are circumstances where an MRI actually may be useful. So if there's enough swelling in the joint, there are times where labral tears will actually show up, that kind of a thing. And there's the acknowledgement of a lot of people don't actually have access to an MRA. So there are limited situations where it is a recommended study. The PRP, as mentioned in the chat, as well as Dr. Moses presented, the evidence for the Ketorolac, that was very nice to see because in my 20 plus years of practice, either it was a steroid injection or a diagnostic injection with some sort of numbing medicine. And to have an option that's supported by the evidence that is non-steroidal is very much nice to know. Were there any other pieces of information that you guys found in there? I know some of what Dr. Moses talked about was new recommendations. Were there any other new findings that you want to draw attention to for the audience? Carrie, there is a question in the chat about where they can find the shoulder guidelines. Yeah, if you guys want to go to www.mdguidelines.com, if you log in, you can go to the ACOM guidelines tool and it will give you that same landing screen that Dr. Berenji was showing. It looks like we do have some questions. There was also one other question about when Dr. Berenji was sharing the algorithm about specifically where they could find that, and so I just wanted to address that briefly, that when you go into the shoulder disorders guideline or any of the other guidelines, there is a section called workflows, and in that workflow section, you will be able to find each of the algorithms that were presented during today's webinar. Dr. Mishner, do you want to address is work hardening of any value and if the patient is non-compliant with physical therapy? Sure, I'll be happy to take that. Thank you, Dr. Kaufman. The question about if they're non-compliant with physical therapy, I would investigate a couple things, and this can be from the physician side, the physical therapy side, or the combination. Is it something with what physical therapy is delivering? Is there a lack of therapeutic alliance with the person who's delivering? Do they need to have a different therapist? So, I would look at that question or that, sorry, I'm looking back at the question. It seems like it has moved. And also, is work hardening of any value? It can be for patients who are, in particular, maybe having psychosocial factors related to fear of using their arm and for particular work activity. So, work hardening can be really helpful with respect to exploring and having them do these activities while they're in a more controlled environment versus returning to work. And I think another question that maybe, Laura, you want to answer just came in. If the employee is not improving after surgery and PT, when would you consider FTE and what's the guidelines for that? So, a functional capacity evaluation is considered if patient, and the guidelines indicate if a patient is returning to work and they need a more detailed assessment in order to determine their ability to return at the same level, or do they need modifications at work? If they're, and what was the first part of the question? I'm scrolling to see the question, but I have not, I can't seem to locate it. This one's still in the open section. If the employee is not improving after surgery, FTE. And again, I keep thinking about if patient isn't improving, I'd sort out what's being delivered in physical therapy, and potentially they need a different physical therapist, and potentially also what, or if it's the same therapist and what they're delivered. So, and I talked about the FTE already. Great. My perspective on the work hardening is it's very, very location specific. So, in Washington State, there are rules about what work, what defines work hardening. And I know that that isn't the case in all jurisdictions, but I know that there are some jurisdictions where there are rules about work hardening. And I know that that isn't the case in all jurisdictions. So, in Washington State, work hardening typically starts at four hours a day, five days a week, and then progresses weekly to eight hours a day, five days a week. And it is very, very few patients that it is appropriate to, and it's only when somebody does not have any graduated return to light duty available or is so truly limited that they need that oversight. So, I imagine the answer would be different in other jurisdictions. Dr. Moses, I'm going to pass on to you, if the patient is willing to pay for PRP and the carrier says it will interfere with the worker's comp claim, any words of advice? Because this isn't something that I would come across in Washington, so I wouldn't know how to answer it. And so, I do think that this is going to be largely jurisdiction specific, like many of the issues that have been brought up thus far. In certain jurisdictions, such as jurisdiction of Colorado, where I work, the patient has the right to pay for any treatment that they want to outside of workers' compensation, and the insurance carrier has no right to tell the patient that they cannot. Other jurisdictions, however, do not have that caveat in their workers' compensation acts. And so, for that question, I would recommend that you contact your state division or bureau of workers' compensation or Department of Labor and Industry in order to determine what the rules are around that based on the interpretation of that statute. Similarly, we've had a lot of questions about psychotherapeutic services and psychological evaluations. Again, when we're dealing with physical mental injuries or physical mental claims, the jurisdiction-specific guidance around how those types of injuries are handled are going to be different from one state to another. And so, unfortunately, this is not a one-size-fits-all question. But I hope that's helpful. Well, thank you again to our speakers for this awesome talk. The slides and recording will be sent out afterwards. Thank you to everyone that attended the webinar. This is a short shout-out for the ACOM conference, AOHG, that's going to be in Philly in April. If you need CME credits, the link will be sent to you. You do the evaluation, and you'll be able to download a certificate. If you have any questions or comments, they can be sent to healthcare at mdguidelines.com. And we just want to say thanks again to our amazing speakers for giving us this insight on the new shoulder disorder guidelines. All right. Thank you, everyone.

webinar

ACOM Clinical Practice Guidelines

shoulder disorders

initial assessment

red flags

diagnostic tests

treatment options

NSAIDs

physical therapy