The Use of a Functional Testing Algorithm (FTA) to ...

Chapter 6

The Use of a Functional Testing Algorithm (FTA) to Make Qualitative and Quantitative Decisions to Return Athletes Back to Sports Following Shoulder Injuries George J. Davies, DPT, MEd, PT, SCS, ATC, CSCS, PES, FAPTA Professor, Department of Physical Therapy, Graduate Program, Armstrong Atlantic State University, Savannah, GA Kevin E. Wilk, DPT, PT, FAPTA Associate Clinical Director, Champion Sports Medicine, Birmingham, AL James J. Irrgang, PhD, PT, ATC, FAPTA Director of Clinical Research, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA Todd S. Ellenbecker, DPT, MS, PT, SCS, OCS, CSCS Clinic Director, Physiotherapy Associates, Scottsdale Sports Clinic, Scottsdale,AZ

Objectives: Upon completion of this course the reader will 1. Identify the components of the Functional Testing Algorithm. 2. Describe a sequential progression for Functional Testing Algorithm of returning to sport following athletic shoulder injury. 3. Apply the Functional Testing Algorithm to assist in clinical decision making for return to sport following athletic shoulder injury. Introduction Many clinicians need to make the decision to return athletes back to sports following a shoulder injury on a regular basis; however, there are 1) very few guidelines published; 2) few objective tests documented to support the clinical decision-making process; and 3) limited evidence to support this process. Performing a PubMed search on this topic revealed no articles specifically dealing with this topic.1 How many of us really have specific criteria that would stand up to critical peer review, high levels of evidence to support our clinical decision making, and medico-legal critical analysis? So what are the very specific criteria we

should use to discharge a patient from rehabilitation back to a high-risk activity like competitive sports? Do we have absolute confidence in our clinical decision making? Almost 90 percent of the orthopaedic literature represents research findings from non-randomized study designs, ranging from the more popular case series to prospective cohort studies, which represent the lower levels of evidence (Levels III-V).2,3 Since evidence-based practice (EBP) is comprised of 1) best research evidence and best practice patterns; 2) patient values and considerations; and 3) clinical experience and expertise,4 and since there are no high levels of evidence guiding the clinical decision making for discharge criteria for patients with shoulder problems, this clinical commentary will integrate the three parts of EBP. Acknowledging there is limited research evidence for this process places more reliance on clinical experience and expertise, particularly because many clinicians need to make these decisions on a frequent basis. A PubMed Search on April 1, 2012, using the terms shoulder injuries AND: return to play, criteria to return to play, return to sports, discharge criteria, evidence1

based practice and clinical decision-making, reveals no studies.1 One method to establish criteria for return to play is to have baseline pre-participation information, and, following an injury, have the athlete return back to “normal” for all the parameters. However, this is not always a practical solution unless comprehensive preseason screening was performed. Furthermore, being medically cleared to return to sports does not mean that the patient/athlete is functionally ready to return to sports! So what happens when an athlete returns to sports after being “cleared by us,” and then they get reinjured? If a physician, physical therapist or athletic trainer allows an athlete to return to sports, they may be legally held responsible if the athlete encounters a serious injury.5 Therefore, the purpose of this article is to describe one example of a functional testing algorithm (FTA) – criterion-based approach – for clinical decision-making to return athletes back to sports following a shoulder injury. So, what else can be done? We recommend using an algorithm, defined as a process consisting of steps, each step depending on the outcome of the previous one. In clinical medicine, an algorithm is a step-by-step protocol for management of a healthcare problem.6 There are numerous examples for lower extremities as demonstrated by several authors.7-12 We are unaware of a FTA that is published for parameters for returning someone back to sports following a shoulder injury, other than this publication.13 Conceptually, a FTA can be thought of as the basic measurements being representative of impairments, strength/power testing indicating functional activity limitations, and functional testing evaluating participation restrictions. Furthermore, a FTA consists of a series of tests (Figure 1). Time and soft tissue healing from the injury or from

First Functional Testing Algorithm for Return to Play, 1998 • Sport-specific testing • Open kinetic chain: Functional Throwing Performance Index • Closed Kinetic Chain Upper Extremity Stability Test • Open kinetic chain isokinetic testing • Kinesthetic/proprioceptive testing • Basic measurements • Visual analog scale Figure 1. First Functional Testing Algorithm for Return to Play, 1998.

a post-surgical condition is always considered relative to performing the FTA testing sequence. Fast forward thirteen years from the original FTA for the shoulder to the present time. Figure 2 illustrates the format that can be used for clinical decision making for returning athletes back to competition following an injury to the shoulder in 2013. Functional Testing Algorithm for Return to Play, 2012 • Sport -pecific testing • Underkoeffler Overhand Softball Throw for Distance • Functional Throwing Performance Index • One-arm seated shot put – medicine ball power test • Closed Kinetic Chain Upper Extremity Stability Test • Open kinetic chain 3-D muscle power testing – BBI • Open kinetic chain isokinetic Testing • Sensorimotor system testing: kinesthetic/proprioceptive testing • Basic measurements • Visual analog scale Figure 2. Functional Testing Algorithm for Return to Play, 2013.

Progression during the FTA to the next higher level of testing difficulty is predicated upon passing the prior test in the series. Each successive test and its associated training regimen places increasing stress on the patient, while at the same time decreasing clinical control. An example of the process of using a FTA is illustrated in Figure 3. Empirically, a therapist can rehabilitate patients faster than ever, because, by testing them, they always know where the patient is in the rehabilitation program, and can focus the interventions specifically on the patient’s particular condition and status. Moreover, the patient only progresses through the level that is appropriate for them. Not every patient performs every test, but they progress through the level that is applicable to their functional activities. As an example, if the patient is not an overhead throwing athlete, they would not perform the overhead throwing tests, such as the Functional Throwing Performance Index. The remainder of this clinical commentary will describe the various components of the FTA for clinical decision making to return athletes back to sports following a shoulder injury, using the limited research available, and the empirically based clinical rationale as to why we are using some of these tests and the progressions. 2

Figure 3. Sequence of progression through a FTA.

Methods The basic measurements include time/soft tissue healing, visual analog pain scale (zero to ten), anthropometric measurements, active range of motion (AROM), passive range of motion (PROM), lower extremity strength and balance testing, core stability testing, and quantitative and qualitative movement assessments, etc.14 As a general guideline, if there is less than ten percent bilateral comparison difference between the involved and uninvolved sides, the patient progresses to the next stage in the FTA. If greater than ten percent bilateral difference, then the patient’s rehabilitation program is focused on the specific parameter, i.e., decreasing swelling, increasing ROM, etc. Sensorimotor system testing can be performed using various methods, such as proprioception tests, kinesthetic tests, active joint replication testing, threshold to sensation of movement, end-ROM reproduction, and movement screening tests. Much of the research on shoulder sensorimotor system has focused on active

angular replication testing because it is felt that active motion is a more functional method of assessing the sensorimotor system.15-18 Performing clinically applicable testing does not require a lot of additional or high technology equipment. A protocol should be established as to what angles are going to be tested. Some protocols19 use just a few angles, whereas some of the original research15 used seven different angles in the ROM: flexion less than 90 degrees, flexion greater than 90 degrees, abduction less than 90 degrees, abduction greater than 90 degrees, external rotation less than 45 degrees, external rotation greater than 45 degrees, and then one measurement for internal rotation. The patient can be seated or supine, the shoulder joint is passively taken to a pre-determined position in the ROM, and the patient is asked to concentrate on that specific angle for ten seconds. A measurement is performed using a goniometer, inclinometer, etc. The patients are then returned back to the starting position. The patient then performs active joint replication. The difference in degrees between the passive position in the ROM and the active angular replication is calculated. The sum of the difference in degrees are divided by the number of angles measured and the difference is recorded.15 Previous numbers reported for active angular replication were males three degrees ± two degrees, and females four degrees ± three degrees.15 If the patient has deficits in this area, the focus of the rehabilitation continues to address the limitations; whereas if the values are within normal limits (WNL), the patient is progressed to the next test in the FTA. The purpose of performing open kinetic chain (OKC) isolated muscle testing is examining each link in the kinematic chain to determine if there are any weaknesses that may be missed if only functional testing is performed. The isolated testing is also performed for the following reasons 1) if one does not test, then one does not know if there is a deficit. 2) if one does not test, then one does not know when a deficit is improving or resolved. 3) one can target the specific muscle that is being tested. 4) one can evaluate for proximal or distal compensations that may also mask any weaknesses. 3

5) a correlation of isolated testing to functional activities does exist.20-24 Testing isolated muscles can be performed with manual muscle testing (MMT), hand-held dynamometry (HHD), or dynamic isokinetic muscle testing. MMT and HHD can also be thought of as field tests, whereas the isokinetic testing is considered laboratory testing. Functional testing is the key, but function is made up of individual links in the kinematic chain; therefore, the importance of performing isolated muscle strength testing exists as well. However, some of the limitations of static MMT are that it is subjective, it only tests one point in ROM, it does not correlate with dynamic muscle testing and it does not correlate with dynamic functional performance.25 HHD allows for objective documentation of static muscle testing. It also has all the limitations of MMT, but at least it provides objective numbers. Turner et al26 have recently performed HHD testing for the scapulothoracic muscles, and rank ordered the muscles and also developed unilateral ratios. Over 1,700 scapulothoracic strength tests were performed and rank ordered from the strongest to the weakest: upper trapezius (UT), serratus anterior (SA), middle trapezius (MT), rhomboids (R), and lower trapezius (LT).

ways to measure isolated dynamic muscle performance and is considered the gold standard for dynamic muscle performance testing. If isokinetic testing is not available, then HHD is preferred. Isokinetic testing results also correlates with functional performance tests.20-24 Four gradient sub-maximal to maximal effort warm ups (25, 50, 75 and 100 percent) and then five maximal test repetitions at 60/180/300 degrees per second are recommended. Descriptive norms for isokinetic testing of the shoulder are listed in Table 1.29-35 Codine et al36 reviewed 87 articles on isokinetics and determined that isokinetic evaluation of the shoulder revealed reliability and validity satisfactory with rigorous test methodology. Descriptive normative values are dependent on several variables including age, gender, body mass index, and type and intensity of activity.29-35 Furthermore, data analysis can include bilateral comparison, unilateral ratio of agonist/antagonist, torque to body weight (relative/normalized data), endurance data, and normative data.29-35 Hurd et al37 demonstrated the importance of normalizing the data relative to body weight to interpret the test results.

A limitation of isokinetic testing is that it only tests in one plane of motion at a time. Davies et al38 completed a reliability and validity study of the Boston Biomotion Instrument (BBI). This is a prototype muscle testing Furthermore, unilateral ratios were developed: device which allows assessment of three-dimensional • Elevation/depression (UT/LT): 2.62 movements with six degrees of freedom. The • Protraction/retraction (SA/R): 1.45 Armstrong Atlantic State University Biodynamics and • Upward rotation/downward rotation (SA/MT): 1.23 Human Performance Center is a beta site for testing 27 Williams et al also measured scapulothoracic protracthis device. Twenty subjects (both arms, for total of 40) tion or retraction, both with and without the involvewere tested over three sessions bilaterally in each sesment of the GH joint. The intra-session reliability using sion. The subjects were randomized for testing on the ICCs was 0.95-0.98 and the inter-session reliability was seated shot put (SSP) and BBI. Subjects performed subICCs 0.94-0.96. When the glenohumeral joint was also maximal to maximal gradient warm-ups, followed by tested along with the scapulothoracic joint, the values three maximum SSP for maximum distance, and three were always higher, but not significantly different. maximum BBI shot put movements, which were measRiemann et al28 performed over ured in maximum power – watts. Table 1. The descriptive normative data for 2,000 HHD testing of the internal ICCs were calculated for the reliand external rotator musculature the FTPI test (Davies, GJ, et.al. JOSPT, ability of the BBI and ranged 1993). based on three selected positions from 0.953 to 0.985. Due to the to establish normative data and lack of a true gold standard for a Norms Males Females unilateral ratios at zero neutral test of upper extremity power, Throws 15 13 degrees, 30º/30º/30º position the SSP, using a six-pound mediAccuracy 7 4 and 90º/90º position. cine ball, was a valid, reliable, FTPI 47% 29% quick and researched field test Range 33-60% 17-41% OKC (isolated joint testing) isokithat could be used to compare to ICC’s - > .90 netic testing are one of the best the BBI. A similar testing posi4

tion was used for the BBI power motion using six pounds of force, simulating the SSP motion. The subjects’ performance on the SSP and BBI was evaluated for correlations using Pearson Product Moment (PPM) to establish the validity of the BBI. The PPM correlations ranged from 0.861 to 0.929. This demonstrates the BBI’s ability to mimic a sporting movement with a relatively high level of control. Consequently, using the BBI allows for specificity of isolated testing and rehabilitation with six degrees of freedom, and design specificity of customized training and rehabilitation programs. Why should closed kinetic chain (CKC) tests be performed for the upper extremity?15,39,40 There are numerous activities, such as gymnastics, rowing, mixed martial arts, karate, Brazilian jujitsu, wrestling, blocking in football, military training drills, calisthenics exercises, etc. that require the use of CKC movements. Davies developed the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST).41 The test protocol consists of two lines on the floor, three feet apart. The participant performs four gradient sub-maximal to maximal warm-ups, with males in the push-up position and females from their knees. The subjects then touch both hands to each line as many times as possible in 15 seconds; 45 seconds of rest; three sets. The number of touches from the three trials is then averaged for the tests results; the original normative data is males – 21 touches, females – 23 touches.41 The ICCs for the CKCUEST were .922. Rousch et al42 tested collegiate baseball players and concluded that the CKCUEST appears to be a clinically useful test for upper extremity function. Pontillo et al43 also used the CKCUEST for screening Division I football players and found the test was a good indicator of potential for injuries during the season. Furthermore, Sween et al44 used the CKCUEST for rehabilitation as well as assessing the patient in a case study. The CKCUEST is considered to be a field test which requires a minimal amount of time and equipment. Riemann and Davies45 have started a series of CKC laboratory tests evaluating the kinetics and kinematics of the upper extremity. One of the first studies evaluated the relationship between two upper extremity functional performance tests and shoulder and trunk muscle strength and a minimal correlation was demonstrated between the tests.45 However, the kinetic forces on the upper extremity measured with AMTI force

plates when performing depth drop landings of the shoulder showed increased forces as the depth of the drop was increased. Additionally, the clap push-up generated the highest forces thought to be the result of the plyometric generated forces to absorb the landing and push back off the ground.46,47 However, when starting to evaluate OKC upper extremity power, there is a lack of research correlating UE strength and power assessments with sporting performance. Abernethy et al48 discussed some of the controversies and challenges of power assessments, and the need for a device or protocol to discriminate upper extremity power performance within an athletic population. The following upper extremity functional tests have been shown to be reliable, valid, and responsive upper extremity power tests. Additionally, minimal equipment is needed and they are easy to administer as a field test.49,50 • One-arm seated SSP dominant arm (six pounds) • One-arm SSP non-dominant arm (six pounds) • Push-up tests for three sets of fifteen seconds • Modified pull-up test for three sets of fifteen seconds • Underkoeffler Overhand Softball Throw for Distance using the one-step (crow hop) throw approach • Davies CKCUEST for three sets of fifteen seconds Gillespie et al51 evaluated 57 males for upper extremity power tests by using a SSP medicine ball throw. They compared a bench power test by moving 50 pounds through extension of the arms, with distance and time measured, compared to eight pound seated shot put distance, with angle of release controlled and not controlled. All results were reliable and valid for both controlled and uncontrolled angles of release suggesting it is a good measure of upper extremity power, independent of technique when throwing. Negrete et al52 described normative data and performed a reliability test of the SSP. A six-pound medicine ball was placed in one hand, palm up with zero degree of shoulder abduction. The subjects performed four gradient sub-maximal to maximal warm-up throws, followed by three maximal effort throws, and the average distance was recorded to the nearest meter. Forty-six subjects were retested and ICCs were used to assess reliability. The ICCs for the SSP tests (six pounds) for the dominant 5

arm was 0.988; for the non-dominant arm was 0.971. Moreover, the minimal detectable changes (MDC) were calculated for the SSP tests and for the dominant arm was seventeen inches; for the non-dominant arm, eighteen inches. Similar to the lower extremity where the single leg hop test is used for limb symmetry index (LSI) and has been shown to be sensitive and specific from several recent studies,53,54,55 we are using the SSP in a similar way for upper extremity LSI. Furthermore, one can normalize the test results to the subjects’ body weight and height. Hurd et al56 recently demonstrated the importance of normalizing the data relative to body weight to interpret the test results. Because limited upper extremity functional performance tests (FPT) exist and FPT involving skill are complicated by upper extremity dominance, Limbaugh et al57 tested collegiate baseball players with the seated medicine ball shot put test. The results demonstrated the combination of greater dominant arm release height, anterior displacement, anterior velocity, vertical displacement, and vertical velocity likely explains the dominant/non-dominant horizontal range difference. The non-dominant arm had greater lateral displacement and lateral velocity which may represent compensatory actions. Limbaugh et al58 completed further research because athletes participating in unilateral activities were assessed to determine if the dominant/non-dominant differences in skill and/or strength/power were related. Although the SSP performance correlates to other UE measures, such as throwing velocity, but is it sensitive to detecting bilateral or population differences? The results demonstrated the dominant arm was significantly better than nondominant in both groups. Sixty-six per cent of the subjects also demonstrated bilateral asymmetry less than ten percent of the time. Although our hypothesis expected baseball players, due to the unilateral overhead activity, to perform better, there were no significant differences between the baseball and non-baseball players. Perhaps baseball players’ strength and conditioning programs reduced unilateral adaptations accompanying baseball activity, or the SSP put may not be sensitive enough to detect adaptations accompanying baseball activity. Negrete et al59 performed a regression analysis to determine the best “field test” as a predictor of performance with the softball throw for distance. The results indicated that the modified pullup was the best predictor of functional throwing

performance. Perhaps the internal rotators which are significant muscles involved in the throwing motion are also primary muscles involved in the modified pullup motion. If the athletes are involved in an overhand throwing sport, then the patients are progressed to the overhand throwing tests. The first throwing test is a sub-maximal controlled throwing test performed in the clinical setting called the Functional Throwing Performance Index (FTPI).15 This test was developed to be performed in an indoor setting with limited space available to assess the overhand throwing motion. This can also be a variation of a quantitative and qualitative movement screening assessment for specificity of throwing performance. The dimensions for the FTPI include a line on the floor fifteen feet from the wall, and a one foot square on the wall, four feet from floor. The subject performs four submaximal to maximal controlled gradient warm-ups (25/50/75/100 percent effort). The player then throws controlled maximum number of accurate throws for 30 seconds. Subjects perform three sets of throws and the results are averaged. The total number of throws are divided by the accurate number of throws and multiplied by 100 to calculate the FTPI. Malone et al60 performed test/retest reliability for the FTPI test with a one month interval between tests. This is a longer time between tests than is normally performed with reliability testing; however, the ICC’s were all above 0.80. If the patient is an overhand throwing athlete, then the patient progresses from the FTPI, which is a controlled submaximal test, to the Underkoeffler Overhand Softball Throw for Distance, which is a maximal effort intensity test using multiple joints of the body in a functional throwing motion. This test is performed by using an overhand throw with a crow-hop. Four gradient sub-maximal to maximal warm-up throws followed by three maximal volitional testing repetitions are performed and an average was recorded to the nearest meter. Collins et al61 performed a reliability study with ICCs above 0.90. The last stage of the FTA consists of sports-specific tests using both quantitative and qualitative analysis. This is individualized to the patient and his/her specific recreational or competitive sports.

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Other considerations include psychological, emotional and social function such as pain, apprehension, fear, and kinesiophobia. The presence of symptoms longer than three months, average pain intensity, flexion ROM index, and fear-of-pain scores all contributed to baseline shoulder function. The immediate clinical relevance of these findings is unclear.62 A component of the comprehensive evaluation of the patient also includes collection of clinical outcome measures to demonstrate the effects of the functional training program. Assessment of clinical outcome should include a variety of clinician-measured outcomes that focus on measures of impaired joint and muscle function, as well as limited activity, which include many of the aforementioned performancebased measures in the FTA. The patient’s perception of their clinical outcome is also important to assess. Patient-reported outcomes measure the patient’s perception of his or her symptoms, activity and participation. Patient-reported outcome measures can be general measures of health status that broadly measure physical, emotional and social function, or specific measures that focus primarily on the assessment of physical function. The most common general patient-reported outcome measure is the Medical Outcomes Study Short-Form 36 Item (SF36) Health Status Measure.63-64 The advantage of using a general patient-reported outcome measure is that it assesses multiple dimensions of health. As such, these measures may detect the influences of injury and rehabilitation on emotional and social function. Additionally, these measures allow for the comparison of the impact of an injury to the shoulder to a variety of other musculoskeletal and non-musculoskeletal conditions. The disadvantages of general patient-reported outcomes are that they tend to be long and more time consuming to administer and score; they may be susceptible to ceiling effects, particularly when completed by individuals, such as athletes, who function at high levels of activity; and the content may not appear to be relevant by athletes and sports medicine clinicians. Specific patient-reported outcome measures include region-specific measures of symptoms, activity and participation affecting the upper extremity or specific conditions affecting the upper extremity and diseasespecific measures for conditions such as rotator cuff tears or shoulder instability. Examples of region-specif-

ic patient-reported outcome measures appropriate for athletes with injuries of the upper extremity include the Disabilities of the Arm Shoulder Hand Index (DASH),65 the DASH Sports Scale,65 American Shoulder and Elbow Surgeons (ASES) Score66 and the KerlanJobe Orthopaedic Clinic (KJOC) Assessment for Overhead Athletes.67 Examples of disease-specific patient-reported outcome measures that may be appropriate to assess the outcome of athletes include the Western Ontario Rotator Cuff (WORC) scale68 and the Western Ontario Shoulder Instability (WOSI) scale.69 The DASH64 consists of 30 items that measure upper extremity physical function (21 items), pain and symptoms (five items) and social and emotional function (four items) for people with disorders of the shoulder, elbow, wrist and hand. The item scores are summed and transformed to a scale that ranges from zero to 100, with higher scores representing greater symptoms and disability. There is good evidence for reliability, validity and responsiveness of the DASH in a variety of populations. The DASH Sports Scale consists of four supplemental items that measure the impact of arm, shoulder and hand conditions on playing sports. The specific questions include difficulty using normal technique, playing sport due to pain, playing support as well as the individual would like and spending usual time practicing or playing sport. Similar to the DASH, the item scores are summed and transformed to a scale that ranges from zero to 100, with higher scores representing greater disability with sports. While potentially useful to assess outcome of athletes, there is little evidence for reliability, validity and responsiveness to support interpretation and use of the DASH Sports Scale. The ASES score65 is a ten-item measure of shoulder pain and function. Pain is assessed on a 10 cm visual analog scale (VAS) and accounts for 50 percent of the total score. The remaining 50 percent of the score is determined by the responses to ten four-point Likertscale questions related to physical function. The pain and physical function scores are summed to create a score that ranges from zero to 100 with higher scores indicating less pain and higher levels of physical function. There is good evidence for reliability, validity and responsiveness of the ASES score to support its interpretation and use.70 The KJOC Functional Assessment for the Overhead Athlete67 is a ten-item scale for overhead athletes with 7

Most studies investigating return to activity measure activity retrospectively by asking individuals after the fact when they returned to activity. This is complicated by the fact that over time, an individual’s participation in sports activity may change for reasons other than the status of the shoulder, such as changes in lifestyle, free time, and work and family obligations. To improve the accuracy of measuring return to activity, pre-injury activity should be measured immediately after injury, return to activity should be measured prospectively during the course of recovery, achievement of important milestones, such as return to throwing, practice and competition should be prospectively documented, and the reasons for decreased activity Psychometrically, there does not appear to be one should be documentpatient-reported outed. Table 2. Psychometic properties for patient-reported outcome come that outper- measures for the shoulder. After passing the forms the others 1 2 3 aforementioned tests, (Table 2). As such, the DASH ASES KJOC particularly the sportchoice of outcome 4 Reliability .82 - .98 .84 - .96 .88 specific tests, with no measure should be Effect Size >.80 >.80 Not Reported residual complaints of determined by the MDC5 2.8 – 5.2 .94 Not Reported pain, increased stiffpatient population MCID6 10.2 6.4 Not Reported ness or effusion with a under consideration 1 Disabilities of Arm Shoulder and Hand Index decrease in range of and the time neces2 American Shoulder and Elbow Surgeons Score motion, and no funcsary to administer 3 Kerlin Jobe Orthopaedic Clinic Functional Assessment for Overhead Athlete tional movement quanand score the out4 Values reported are intra-class correlation coefficients 5 Minimal detectable change titative or qualitative come measure. 6 Minimum clinical important difference deficits, the athlete For an athletic popucan be progressed lation, the ultimate outcome after injury and/or surback into activities. The athlete returns to sport specifgery is the ability of the athlete to return to prior level ic training programs first, practice simulations, pracof sports in terms of intensity, frequency, duration and tices, scrimmages, and then competition in his/her absence of symptoms. Brophy et al71 developed the respective sport. Shoulder Activity Scale (SAS), which is useful for measuring return to activity athletes that participate in overSummary head throwing sports. The SAS consists of five quesThe purpose of this clinical commentary describes one tions (carrying eight pounds, overhead objects, approach to a FTA. Typically our clinical decision makweightlifting with arms, swinging motion and lifting ing, based on history, subjective exam, objective physigreater than 25 pounds), each rated in terms of frecal exam, imaging, etc., states the athlete is ready to quency that activity is performed ranging from return to activity. However, if we also have all the funcnever/less than once per month to daily. The items are tional tests to support the clinical decision making, it summed for a total score that ranges from zero to twenprovides quantitative and qualitative data to strengthen ty, with higher scores indicating higher activity levels. the decision to return the athlete back to activity The SAS also includes two items related to participasafely. tion in contact and overhead sports that are not scored. Test/re-test reliability was determined to be .92 over a one-week period and the MDC was determined to be 3.8. The SAS is related to other activity measures but not age. disorders affecting the shoulder and elbow. This includes four items related to pain, one item related to interpersonal relationships related to athletic performance, and five items related to function and athletic performance. Each item is scored on a 10 cm VAS. The items are summed to create a score that ranges from zero to 100 with higher scores representing better function and athletic function and less symptoms. Evidence for reliability, validity and responsiveness of the KJOC Functional Assessment for the Overhead Athlete score has been provided by Alberta et al,67 and normative scores for overhead throwing athletes without symptoms were also recently provided.

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References 1. PubMed Search, April 1, 2012 2. Obremskey WT, et al. Level of evidence in orthopaedic journals. J Bone Joint Surg Am. 2005;87:2632-2638. 3. Bhandari M. Design, conduct, and interpretation of non-randomized orthopaedic studies: a practical approach. (All) evidence matters. J Bone Joint Surg Am. 2009;91:Suppl 3:1. 4. Sackett DL, Straus SE, Richardson WS, et al. EvidenceBased Medicine. New York, NY: Churchill Livingstone; 2000. 5. Creighton DW, et.al. Return-to-play in sport: a decision-based model. Clin J Sports Med. 2010;20(5):379385. 6. Taber’s Cyclopedic Medical Dictionary. Philadelphia, PA: F.A. Davis Company; 1997. 7. Davies GJ, Zillmer DA. Functional progression of a patient through a rehabilitation program. Ortho Phys Ther Clin North Am. 2000;9:103-118. 8. Myer GD, Chimielewski TL, Kauffman D, Tillman S. Plyometric exercise in the rehabilitation of athletes: physiological responses and clinical application. J Ortho Sports Phys Ther. 2006;36(5):308-319. 9. Hurd W, Axe M, Snyder-Mackler L. A 10-year prospective trial of a patient management algorithm and screening examination for highly active individuals with anterior cruciate ligament injury, part 1: outcomes. Am J Sports Med. 2008;36(1):40-47. 10. Meyer GD, Schmitt LC, Brent JL, et al. Utilization of modified NFL combine testing to identify functional deficits in athletes following ACL reconstruction. J Ortho Sports Phys Ther. 2011;41(6):337-387. 11. Yenchak AJ, Wilk KE, Arrigo CA, et al. Criteria-based management of an acute multi-structure knee injury in a professional football player: a case report. J Ortho Sports Phys Ther. 2011;41(9):675-686. 12. Barber-Westin SD, Noyes FR. Factors used to determine return to unrestricted sports activities after ACL-R. Arthroscopy. 2011;27:1697-1705. 13. Davies GJ, Heiderscheit B, Clark M. Closed kinetic chain exercises: functional applications in orthopaedics. In: Wadsworth, C, ed. Strength and Conditioning Applications in Orthopaedics. Home study course. LaCrosse, WI: Orthopaedic Section, APTA; 1998. 14. Davies GJ, Gould J, Larson R. Functional examination of the shoulder girdle. Phys Sports Med. 1981;9(6):82104. 15. Myers JB, Lephart SM. Sensorimotor deficits contributing to glenohumeral instability. Clin Orthop Relat Res. 2002;400:98-104.

16. Myers JB, Wassinger CA, Lephart SM. Sensorimotor contribution to shoulder stability: effect of injury and rehabilitation. Man Ther. 2006;11(3):197-201. 17. Davies GJ, Hoffman SD. Neuromuscular testing and rehabilitation of the shoulder complex. J Ortho Sports Phys Ther. 1993;18(2):449-458. 18. Ellenbecker TS, Davies GJ.Proprioception and neuromuscular control. In: Andrews J, Harrelson GL, Wilk K, eds. Physical Rehabilitation of the Injured Athlete, 3rd. Ed. Philadelphia, PA: W.B. Saunders; 2012. 19. Voight ML, Hardin JA, Blackburn TA, et al. The effects of muscle fatigue on and the relationship of arm dominance to shoulder proprioception. J Orthop Sports Phys Ther. 1996;23(6):348-352. 20. Ellenbecker TS, Davies GJ, et al. Concentric vs eccentric isokinetic strengthening of the rotator cuff: objective data vs functional test. Am J Sports Med. 1988;16(1):64-69. 21. Mont MA, Cohen DB, Campbell KR, et al. Isokinetic concentric versus eccentric training of shoulder rotators with functional evaluation of performance enhancement in elite tennis players. Am J Sports Med. 1994;22(4):513-517. 22. Treiber FA, Lott J, Duncan J, et al. Effects of Theraband® and lightweight dumbbell training on shoulder rotation torque and serve performance in college tennis players. Am J Sports Med. 1998;26(4): 510-515. 23. Davies GJ, Riemann BL, Byrnes E, et al. The effectiveness of blocked versus random exercise training programs using isolated shoulder exercises and selected outcome measures. Abstract accepted, ISAKOS 8th Biennial Congress, Rio de Janeiro, Brazil, May, 2011. 24. Birke C, Tankovich M, Gignilliat M, et al. The effectiveness of isolated exercise shoulder rehabilitation program on patients with shoulder pain, and detraining effects. Poster presentation. APTA-CSM, Chicago, IL, 2012. 25. Ellenbecker TS. Muscular strength relationship between normal grade manual muscle testing and isokinetic measurement of the shoulder internal and external rotators. Isok Exerc Sci. 1996;6:51-56. 26. Turner N, Ferguson K, Wetherington B, et al. Establishing unilateral ratios of scapulothoracic musculature using hand-held dynamometry. J Sport Rehab. 2009;18:502-520. 27. Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther. 2009;39(2):105-117.

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28. Riemann BL, Davies GJ, Ludwig L, et al. Hand-held dynamometer testing of the internal and external rotator musculature based on selected positions to establish normative data and unilateral ratios. J Shoulder and Elbow Surg. 2010;19:1175-1183. 29. Davies, GJ. A Compendium of Isokinetics in Clinical Usage. First Edition. La Crosse, WI: S & S Publishers; 1984. 30. Wilk KE, Andrews JR, Arrigo CA, et al. The strength characteristics of internal and external rotator muscles in professional baseball pitchers. Am J Sports Med. 1993;21(1):61-66. 31. Wilk KE, Andrews JR, Arrigo CA. The abductor and adductor strength characteristics of professional baseball pitchers. Am J Sports Med. 1995;23(6):778. 32. Davies GJ, Ellenbecker T, Heiderscheidt B, et al. Clinical examination of the shoulder complex. In: Tovin B, Greenfield B, eds. Evaluation and Treatment of the Shoulder: An Integration of the Guide to Physical Therapist Practice. Philadelphia, PA: F.A. Davis; 2001. 33. Ellenbecker TS, Davies GJ. The application of isokinetics in testing and rehabilitation of the shoulder complex. J Ath Train. 2000;35:338-350. 34. Davies GJ, Wilk KE, Ellenbecker TS. Isokinetic exercise and testing for the shoulder. In: Andrews JR, Wilk KE, Reinold M, eds. The Athlete's Shoulder. Philadelphia, PA: Elsevier; 2009. 35. Davies GJ, Ellenbecker T. The scientific and clinical application of isokinetics in evaluation and treatment of the athlete. In: Andrews J, Harrelson GL, Wilk K, eds. Physical Rehabilitation of the Injured Athlete, 3rd Edition. Philadelphia, PA: W.B. Saunders; 2012. 36. Codine P, Bernard PL, Pochelle M, et al. Isokinetic strength measurement and training of the shoulder: methodology and results. Ann Readapt Med Phys. 2005;48:80-92. 37. Hurd WJ, Morrey BF, Kaufman KR, et al. The effects of anthropometric scaling parameters on normalized muscle strength in uninjured baseball pitchers. J Sport Rehab. 2011;20:311-320. 38. Davies GJ, Campbell J, Waterman W. Reliability and validity of the Boston Biomotion Instrument in the measure of upper extremity power and a comparison to the seated shot put test. Platform presentation. ISAKOS Meeting, Rio de Janeiro, Brazil. May, 2012. 39. Ellenbecker TS, Manske R, Davies GJ. Closed kinetic chain testing techniques of the upper extremities. Ortho Phys Ther Clin of North Am. 2000;9:219-230. 40. Ellenbecker T, Davies GJ. Closed Kinetic Chain Exercise: A Comprehensive Guide to Multiple Joint Exercise. Champaign, IL: Human Kinetics; 2001. 41. Goldbeck T, Davies GJ. Test/re-test reliability of a closed kinetic chain upper extremity stability test: a Clinical Field Test. J Sport Rehab. 2000;9:35-45.

42. Rousch JR, Kitamura J, Waits MC. Reference values for the closed kinetic chain upper extremity stability test (CKCUEST) for collegiate baseball players. Inter J Sports Phys Ther. 2007;8(3):159-163. 43. Pontillo M, Sennett BJ, Spinelli BA. Prediction of inseason shoulder injury from pre-season testing in D-I collegiate football players. J Ortho Sports Phys Ther. 2012;42:SPL4. 44. Sweeny AE. Return-to-sport rehabilitation for a rugby athlete following posterior shoulder stabilization procedure. J Ortho Sports Phys Ther. 2012;42:SPL18. 45. Riemann, BL, Davies, GJ. Relationship between two upper extremity functional performance tests and shoulder and trunk muscle strength. Med Sci Sports Exerc. 2009;41(5):S393. 46. Koch J, Riemann BL, Davies GJ. Ground reaction force patterns in plyometric push ups. J Strength Cond Res. (In press, 2012) 2012;26(8):2220-2227. 47. Moore LH, Tankovich MJ, Riemann BL, et al. Kinematic analysis of four plyometric push-up variations. Inter J Exer Sci.(First submission in review, 2012) 2012;5(4):334-343. 48. Abernethy P, Wilson G, Logan P. Strength and power assessment issues, controversies and challenges. Sports Med. 1995;19(6):401-417. 49. Rex N, Clark S, Austin T, et al. Upper extremity power measures and determining a gold standard. DPT Capstone Research Project. 2012. 50. Ansley M, McBride B, Overstreet A, et al. Multicenter study for the correlation between field tests of upper extremity function and power. DPT Capstone Project. 2009. 51. Gillespie J, Keenum S. A validity and reliability analysis of the seated shot put as a test of power. Journal of Human Movement Studies. 1988;13:97-105. 52. Negrete RJ, Hanney WJ, Kolber, MJ, et al. Reliability, minimal detectable change and normative values for tests of upper extremity function and power. J Strength Cond Res. 2010;24:3318-3325. 53. Meyer GD, Schmitt LC, Brent JL. Utilization of modified NFL combine testing to identify functional deficits in athletes following ACL reconstructions. J Ortho Sports Phys Ther. 2011;41:377-387. 54. Arden CL, Webster KE, Taylor NF. Return to pre-injury level of competitive sport after ACL Reconstruction surgery. Am J Sports Med. 2011;39:538-543. 55. Grindem H, Logerstedt D, Eitzen I, et al. Single-legged hop tests as predictors of self-reported knee function in non-operatively treated individuals with ACL injury. Am J Sports Med. 2011;39:2347-2354. 56. Hurd WJ, Morrey BF, Kaufman KR. The effects of anthropometric scaling parameters on normalized muscle strength in uninjured baseball pitchers. J Sport Rehab. 2011;20:311-320. 10

57. Limbaugh GK, Riemann BL, Davies GJ. Comparison of standing single arm shot put performance between limbs with different loads in collegiate baseball players. Platform presentation, NATA, Philadelphia, PA, June, 2010.

70. Kirkley A, Griffin S, McLintock H, et al. The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability. The Western Ontario Shoulder Instability Index (WOSI). Am J Sports Med. 1998;26(6):764-772.

58. Limbaugh GK, Traylor D, Riemann BL, et al. Comparing one-arm seated shot put throw performance between baseball and non-baseball athletes. Poster presentation, ACSM, Seattle, WA., 2010. 59. Negrete RJ, Davies GJ, Hanney WJ, et al. Modified pull-up is the best predictor of a softball throw for distance. Int J Sports Phys Ther. 2011;6(2): 104-111.

71. Cook C, Hegedus E, Goode A, et al. Relative validity of the modified American Shoulder and Elbow Surgeons (M-ASES) questionnaire using item response theory. Rheumatol Int. 2008;28(3):217-223.

60. Malone T. Masters Thesis, 1995. 61. Collins DR, Hedges PB. A Comprehensive Guide to Sports Skills Tests and Measurements. Springfield, IL: Charles C. Thomas; 1978:330-333. 62. Wilk KE, Obma P, Simpson CD, et al. Shoulder injuries in the overhead athlete. J Orthop Sports Phys Ther. 2009;39(2):38-54. 63. Lentz TA, Barabas JA, Day T, et al. The relationship of pain, intensity, physical impairment, and pain-related fear to function in patients with shoulder pathology. J Ortho Sports Phys Ther. 2009;39:270-277. 64. Ware JE, Jr., Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I: Conceptual framework and item selection. Med Care. 1992;30(6):473-483. 65. Brazier JE, Harper R, Jones NM, et al.Validating the SF-36 health survey questionnaire: new outcome measure for primary care. BMJ. 1992;305(6846):160164. 66. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;(6):602-608. 67. Michener LA, McClure PW, Sennett BJ. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity and responsiveness. J Shoulder Elbow Surg. 2002;11(6):587-594. 68. Domb BG, Davis JT, Alberta FG, et al. Clinical follow-up of professional baseball players undergoing ulnar collateral ligament reconstruction using the new Kerlan-Jobe Orthopaedic Clinic overhead athlete shoulder and elbow score (KJOC Score). Am J Sports Med. 2010;38(8):1558-1563. 69. Wessel J, Razmjou H, Mewa Y, et al. The factor validity of the Western Ontario Rotator Cuff Index. BMC Musculoskelet Disord. 2005;4;6:22.

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Review questions 1. A functional testing algorithm (FTA) involves which of the following concepts a. Progression during the FTA to the next higher level of testing difficulty is predicated upon passing the prior test in the series. b. Each successive test and its associated training regimen places increasing stress on the patient. c. Decreases clinical control with progressive testing to stress the patient but not putting them into a compromising position. d. All of the above 2. Basic measurements in the FTA include all but the following criteria a. AROM b. Lower extremity strength and balance testing c. Closed kinetic chain upper extremity stability test d. Core stability testing 3. Sensorimotor system testing of the shoulder can be performed in numerous ways. Which of the following is not a common technique for measuring shoulder proprioception? a. H-reflex testing b. Active angular joint replication c. Threshold to sensation of movement d. End ROM reproduction 4. Which of the following is not a valid reason for performing open kinetic chain (OKC) isolated testing? a. To check for proximal or distal weaknesses from the injury site b. For serial assessment of the weak link in the kinematic chain c. It allows assessment of the entire extremity to target specific weaknesses d. Because isolated testing actually correlates with functional performance 5. In performing hand-held dynamometry of the scapulo-thoracic muscle, the muscles were rank-ordered from the strongest to the weakest muscle groups. Which of the following accurately indicates this ranking? a. UT, SA, MT, LT R b. UT, MT, R, SA, LT c. UT, SA, MT, R, LT d. UT, R, SA, MT, LT

Test questions 1. The closed kinetic chain upper extremity stability test tests for power endurance of the upper extremity and the protocol uses the following a. Three fifteen-second tests with 45 second rests b. Three 45-second tests with fifteen second rests c. Three fifteen-second tests with fifteen second rests d. Three 45 second tests with 45 second rests

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2.

When performing closed kinetic chain (CKC) plyometric depth drop landings of the shoulder, which of the following motions produced the highest ground reaction forces? a. Drop landing from one board b. CKC upper extremity stability test c. Clap push-up d. CKC cross-over test

3.

The seated shot put test has been used to check for limb symmetry index between the upper extremities. The minimal detectable change was documented to be a. Dominant arm: seventeen inches; non-dominant arm: eighteen inches b. Dominant arm: eighteen inches; non-dominant arm: fifteen inches c. Dominant arm: seventeen inches; non-dominant arm: thirteen inches d. Dominant arm: eighteen inches; non-dominant arm: seventeen inches

4. Examples of region-specific patient-reported outcome measures appropriate for athletes with injuries of the upper extremity include all but the following scale a. DASH Sports Module Scale b. American Shoulder and Elbow Surgeons (ASES) Score c. Western Ontario Shoulder Instability (WOSI) scale d. Kerlan-Jobe Orthopaedic Clinic (KJOC) Assessment for Overhead Athletes 5. Which of the following is not a common general patient-reported outcome measure scoring system? a. Medical Outcomes Study Short-Form 36 Item (SF-36) b. Global Rating of Change (GROC) c. Tampa Bay Kinesiophobia Index d. Health Status Measure

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