Clinical Decision Making: Utility of Physical Therapy for Glenohumeral Osteoarthritis Cases with Varying Radiographic Severity (Physician Update, March 2024)

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EVIDENCE-BASED PRACTICE UPDATE

March 2024

 

Clinical Decision Making:  Utility of Physical Therapy for Glenohumeral Osteoarthritis Cases with Varying Radiographic Severity

 

 by Mike Napierala, PT, SCS, CSCS, FAFS

 

What would you do?

A 72 yr old golfer comes for evaluation of chronic progressive shoulder pain with associated loss of motion that has led to increased disability during ADL, yardwork, fitness, and golf.  Clinical exam shows moderate limitation of elevation ROM asymmetrically, along with all other ranges tested.  Strength is minimally affected but painful in most directions and producing palpable/audible crepitus especially with resisted abduction and abducted rotations.  Plain films show mild-moderate severity osteoarthritis on one side and moderate-severe on the other side, , correlating to his asymmetric symptoms.  The patient wishes to avoid any surgery as long as possible but does want to remain active.  .  

I would do the following …

1. Perform an intra-articular corticosteroid injection on at least the most severe shoulder and FU in 2-3 wks to consider physical therapy referral.
2. Prescribe NSAID’s and topical Voltaren gel along with a home program sheet of ROM drills, FU in 4-6 wks.
3. Prescribe physical therapy to include Class IV laser and joint mobilization along with exercise, FU in 4-6wks.
4. Recommend viscosupplementation vs biologic injection options and proceed per patient choice.

 

CURRENT EVIDENCE

Bauman AB, Indermuhle T, et al.  Comparing outcomes after referral to physical therapy for patients with glenohumeral osteoarthritis based on radiographic osteoarthritis severity:  A retrospective analysis.   Cureus.  15(8), 2023.

https://assets.cureus.com/uploads/original_article/pdf/173193/20230905-28062-n725ly.pdf

*** We modified the  Newsletter format to better match your time constraints.  The more in-depth “Peak Perspective” will now be contained below in more “summary” form.  We invite you to reach out to us at PT@peakptrochester.com or call our office at 585-218-0240 to further discuss this article or specific patient needs if you wish.  The abstract can be found after the case study.

PEAK PERSPECTIVE SUMMARY

Radiographic signs of glenohumeral (GH) osteoarthritis have been seen in 17-20% of adults over age 65.  As physicians seeing increasing numbers of the aging population for shoulder pain and disability being aware of current best practices based on available evidence is not only necessary but helps in clinical decision making beyond “standards of care” that may have been developed years or decades earlier that were based on less available quality studies or on residency/fellowship practices habits primarily.  While there is a significant amount of literature examining the efficacy of injections for glenohumeral osteoarthritis (GHOA) there remains a very limited amount of data available to discern the efficacy of conservative care based physical therapy.  The American Physical Therapy Association (APTA) has developed a Clinical Practice Guideline (CPG) for GHOA in conjunction with representatives from AAOS and also AAPMR.  (https://academic.oup.com/ptj/article/103/6/pzad041/7146561).  Unfortunately higher levels for “strength of evidence” only exist for limited aspects of GHOA care decision making.   

Rene Dubois has been quoted as saying “The measurable drives out the important” - a statement considered inflammatory and a bit hyperbolic and overgeneralizing by some, yet holds some critical truth as well.  Beyond the more variable and bias-risked world of case study and professional experience level evidence,  the “truths” of orthopedics and rehabilitation are hoped by most to lie in evidence that reaches randomized clinical trial (RCT) levels of study and scrutiny.  As studies are done exploring “mechanisms” and measuring “outcomes” the collective results are intended to drive clinical decision making.  But what about when a topic has not been well studied…or studied thoroughly?  Then what?  

This is the case to a great extent for GHOA.  There simply is a lack of high level data to help physicians and PT’s alike make determinations on best practices.  The fact remains that many, in fact, most patients with GHOA are not presently at a level that requires escalation to total shoulder arthroplasty (TSA) or a reverse-TSA.  A common non-operative treatment of choice has been corticosteroid injections (CSI).  There is at least some controversy over the use, especially repeated use, of CSI - while acutely helpful oftentimes, also has some evidence suggesting potentially negative downstream impact.  Some studies, particularly in the knee, have even demonstrated a risk of early progression to arthroplasty from CSI.    

Additionally, some evidence exists suggesting biologics, like PRP, may show better/longer (+) changes for GHOA patients than standard steroid injection (Saif et al, Egyptian Rheumatology and Rehabilitation, 2018).  This presents some dilemma and challenge since steroid injections are covered by insurance while PRP is not and can only be done as an added cash based service, meaning the majority of patients will choose CSI first when given options.  Patients often indicate that PRP was never even discussed as an option despite the evidence suggesting mainly short term benefits and a potentially concerning risk profile of CSI  in combination with at least some (+) evidence for PRP.  Some would suggest this begs the question of whether treatment decision making is being based more on tradition/habit or truly evidence based rationales.  

Bauman et al provide some low level evidence that, like physical therapy for more common OA conditions of the hip and knee, shoulder OA can benefit from physical therapy as well.  While certainly no conservative treatments have been proven to literally restore normal chondral anatomy and function, the evidence does show that patients receiving physical therapy can reduce symptoms and increase function with a low cost and very low risk treatment (PT)  that also actively involves them in positively affecting their own care and outcomes.  

Their retrospective review of 220 patient cases divided between no GHOA (n=104), mild radiographic GHOA (n=61) and moderate/severe GHOA (n=55) referred to PT for shoulder pain were measured for pain (VAS), AROM into abduction, and Quick DASH scores.  Post hoc testing showed no difference between groups for pain improvement, for abduction AROM, or for Quick DASH findings.  While they showed only small (but statistically significant) short term improvements in pain, AROM, and disability across the varying severity levels of GHOA there was no significant association of the magnitude of change with severity.  Only the mild GHOA patient group experienced clinically meaningful pain reduction (mean 2.4 pts reduction vs 1.4 no GHOA and 1.5 mod/severe GHOA).  The mod/severe GHOA group actually showed the highest abduction AROM mean improvement (19.8⁰ vs no GHOA 15.2⁰ and mild OA 8.3⁰).  

While surgical care for severe shoulder OA has trended upward significantly over the past decade with advances in technology and surgical techniques there does not appear to be an associated significant rise in the frequency of preoperative physical therapy utilization that might be expected.   Physicians and orthopedic surgeons are at risk for assessing that patients with moderate and severe GHOA may be too advanced in their condition to benefit from physical therapy. Even for patients who likely may eventually need TSA or R-TSA there remains the need to optimize pain relief and function at low cost and low side effects.   Bauman et al, albeit only providing low level retrospective analysis level data, demonstrate that even with more advanced GHOA physical therapy can be effective.

One concern regarding the design and data presentation is that physical therapy was allowed to be “real world” in regard to its variability.   There were no minimums or provider skill levels noted for manual therapy, no parameters for type and extent of exercises done,  HEP compliance was not monitored, and a more typical bout of PT care for longer time period was not required  - this study’s inclusion was only > 2 PT visits.  All of these lead to the risk of “watering down” the efficacy all while still lumping in results as being definitive of “physical therapy care.”   Nevertheless, this “real world” design strengthens the findings to some extent since despite this variability significant changes were nevertheless produced by treatments.  It likewise produces a caution in believing that “only” minor changes can be made with physical therapy for GHOA. Our experience is certainly that skilled manual therapy is key in these cases along with very careful customized therapeutic exercise.  So often we see failed PT cases who eventually do very well but initially were provided standardized shoulder ROM and strengthening protocol sheets to follow, without adequate regard for their biomechanical nuances needed.  Obviously further quality studies are needed to provide better evidence.  

The limited number of mod/high quality studies left the APTA’s CPG for GHOA non-operative care guidelines reliant on clinical expertise level recommendations rather than moderate or high quality evidence for many of the areas of care relevant to decision making.  Where specific GHOA data may be lacking the literature demonstrating beneficial outcomes of manual therapy and exercise for hip and knee OA may be considered supportive.  And like hip and knee OA, shoulder OA, due at least in part to the expected ROM limitations/barriers that exist, become very reliant on effectively identifying kinetic chain needs - in this case, for especially scapular and thoracic function.  Traditional PT approaches focusing on local shoulder needs and approaches often fail then to identify key needs of pectoralis minor restrictions to elevation ROM ease or of thoracic extension and rotation function necessary for UE reaching in ADL or work and recreational activities.   

The case below illustrates the efficacy possible with skilled PT care in a unique case of a patient with (B) GHOA at differing severities. 

 

THE PEAK PERFORMANCE EXPERIENCE

John said:  “I’m feeling much better now, I’ve got less crepitus, and I played 18 holes of golf without any issues!”

History:  71 yr old male with 6+ yr gradual onset of L shoulder pain w fitness wt lifting but also had R shoulder partial RC tear debridement in 2007.  After Covid based concerns he returned to the gym in mid-2023. 

Subjective:  Initial verbal pain scale max was L 2/10 and R 1/10 with associated function ratings of L 80% and R 90%.   CC included pain and limitation with dressing, OH reaching ADL especially limited with any loading, playing accordion, sleep disturbance and AM symptoms. 

Objective:   

 

(*=pain)	Initial Eval  L/R	Re-Eval  9 wks  L/R
Quick DASH	20%	7% L   5% R
Thor Rot sitting	500/580	630590
Pec Minor (Retraction in Elev)	Max/Min+	Mod/< Min
AROM flexion	1150 */1450*	1280/1620
IR up back	L2*/T12*	T12/T10
Neut ER	150/330	300/600
Abd ER	600/750	720/780
Isometric Jobe	3.3kg*/4.4 kg	5.6/6.4 kg
Isometric Neut IR	6.7kg/10.5kg	15.1/16.5 kg
Isometric Abd ER	4.4kg/6.4 kg	9.4/9.9kg
Fxn - OH reach  (L 70” and R 75.5”)	5#  > 50x ea w ↑ IR	12#                   L 12x, R 25x
Fxn - Row pulley	@ 1mo 50#     22x/32x	50# cable    37x/40x

 

Key Findings:  Pec minor length significantly limited L > R  w upward rotated scapula, mod+ crepitus L and minimal R.  All AROM was limited and most were painful.  Isometrics were initially symptomatic only with L flexion and Jobe though all were weak.  Thoracic extension only min limited but asymmetrically limited in R > L thoracic rotation.  Pt’s subjective pain reporting and function ratings were out of proportion to the symptoms noted and extent of limitation on objective testing.  

Treatment: 

Manual therapy: Pec minor release/mobilization and GH joint mob’s for L > R shoulder.    

Exercise: PROM stretching program following mob’s and done as HEP BID-TID for all major motions/directions/planes of shoulder…L > R.  Customizing paths was necessary to avoid impingement sx often with elevation especially and with Abd’d IR.   PRE were added once ROM work was fully in place.  Pulling and rotational work was advanced before elevation work.  Elevation PRE began with multi-joint incline pressing before long lever work was done in order to control extension/adduction moments at the shoulder.  Functional rotational combination trunk drills done especially regarding golf concerns.

Outcome: Pt successfully resumed 18 holes golfing and increased fitness wt lifting and ADL.  Though his subjective ratings were only L 80% - - - > 80% and R 90- - - >98% his gross shoulder Quick DASH changed from 20% global to L 7% and R 5%, indicating with regard to rating the same activity categories he did, in fact, note significant changes in both shoulders, including the more moderately arthrtitic L shoulder.  

 

ABSTRACT

Background:  Glenohumeral osteoarthritis (GHOA) is a common cause for musculoskeletal pain and disability.  Conservative care choices, including physical therapy, sometimes depend on radiographic severity of the GHOA.   

Purpose:  This retrospective analysis aimed to examine how physical therapy impacts outcomes for patients with varying degrees of GHOA severity radiographically.

Type:  Retrospective analysis.

Methods:  Patients attending outpatient physical therapy between 2016 and 2022 for shoulder pain who had radiographs within two years of the initial PT visit, had at least one PT follow up visit following evaluation, and no history of shoulder surgery had charts reviewed for outcome measures of pain, abduction AROM, and Quick DASH scores.  The 220 patients were divided into No GHOA (n=104), Mild GHOA (n=61), and Mod/Severe GHOA (n=55) groups based on radiographic findings.  

Findings:  The mean age was 62.2 yrs and mean number of PT sessions 7.8x.  Post hoc analysis showed no significant difference between any of the three groups’ improvements in pain, magnitude of AROM gain, or Quick DASH improvements based on the severity of radiographic GHOA.  

Author's Conclusion:  Patients with GHOA have small but statistically significant short term improvements in pain, abduction AROM, and disability regardless of GHOA severity and no association between magnitudes of improvement with radiographic severity.  Only patients with mild OA showed clinically significant improvements in pain.  

You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals.

Call us at 218-0240 to discuss your patient's specific needs.  

Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester.  

We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients.  No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. 

 

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