Evidence-based

Shoulder Rehabilitation
Presented by
Scott Toale, PT, MPT, Cert. MDT
Facility Director/Physical Therapist
stoale@phoenixrehab.com

PHOENIX Rehabilitation and Health Services, Inc.

Horsham, PA

www.phoenixrehab.com

IARP Conference 2013

Evidence-based Shoulder Rehabilitation
Objectives:
1. Review Shoulder Anatomy
2. Understand Occupational Shoulder Musculoskeletal Disorders
(MSDs)
3. Understand Medical Assessments of the Shoulder
4. Understand Role of the Physical Therapist (PT):
- As Part of Industrial Health Care Team
- Evaluation/Assessments
- Interventions/Post-Operative Protocols
5. Define Functional Outcome Measures
6. Understand Return-to-Work (RTW) Strategies
1. Review of Shoulder
Anatomy/Kinesiology
Bones of the Shoulder Girdle
Ligaments/Joints of the Shoulder Girdle (Gleno-humeral Joint)
Ligaments/Joints of the Shoulder
(Scapulo-Thoracic Joint)
 Muscles of the Shoulder Girdle:
“Rotator Cuff” ‘SITS’
1. Supraspinatus
• Initiates abduction
• *Most often torn
2. Infraspinatus
3. Teres Minor
• Both externally
rotate humerus
4. Subscapularis
• Internally rotates
humerus
Muscles of the Shoulder Girdle
(Posterior View)
 Muscles of the Shoulder Girdle
(Anterior View)

1. Pectoralis Major
• adducts humerus to midline
2. Pectoralis Minor
• draws scapular inferior/medial
3. Deltoid
• elevates humerus
4. Biceps Brachii
• raises humerus forward
• flexes elbow
Mobility on Stability
Occupational Stresses to the Shoulder
 2. OCCUPATIONAL SHOULDER
MUSCULOSKELETAL DISORDERS (MSD)
 Jobs Most at Risk for Injuries
Days Away from Work (2011)
(www.bls.gov/news.release/osh2.nr0.htm)

Occupation Days Away from Work Cases Median Days

Away from
Work
Laborers and freight- stock, 56,950 9
and material movers-hand

Nurses aides, orderlies, 47,840 5

attendants
Janitors and Cleaners 44,850 7
Heavy and tractor-trailer 44,120 20
truck drivers
Police/Sheriff’s patrol 33,590 10
officers
 Median Days Away From Work
(%) of Total MSDs
Shoulder vs. Back (2011)
Shoulder Back
ALL OCCUPATIONS 21 (13%) 7 (42%)
Nurses assistants 7 (13%) 5 (55%)
Laborers and freight- stock, 30 (16%) 7 (44%)
and material movers-hand

Janitors and Cleaners 21 (12%) 6 (49%)

Heavy and tractor-trailer 35 (16%) 13 (36%)

truck drivers

Registered Nurses (2010) 13 (13%) 7 (53%)

(www.bls.gov/news.release/osh2.nr0.htm)
 Top 10 OSHA Violations of 2012
(Lane 2012, www.nsc.org)

1. Fall Protection 6. Machine Guarding

2. Hazard Communication 7. Powered Industrial Trucks
3. Scaffolding 7. Electrical – Wiring Methods
4. Respiratory Protection 8. Control of Hazardous Energy
5. Ladders 9. Electrical - General
Risks …
Risks …
Risks …
Risks …
Risks …
 Avoid an OSHA Inspection
“They (companies) may need to know that 90 percent
of OSHA inspections are generated by a call from an
angry worker.”

“Companies should not set a goal of ‘no reported

injuries’; rather they should use ‘no lost time’ as a
goal.”

(Catapang , Advance 2012)

Shoulder Diagnoses

• Must Rule Out:

– Cervical origin

– Brachial plexus
neuropathy

– Thoracic outlet
syndrome

– Systemic problem

– Symptom
magnifier?
 NCCI Research Brief:
Thinking About the Aging Workforce
(Restrepo 2005)

Lost-Time Frequency Ranks by Age for the Top 10 Diagnosis Codes

 Since 2000/2001 Rotator Cuff Sprain
Ranked In Top 10 for ages 35 and Older
(NCCI Research Brief, Restrepo 2012)

Accident Years 20-24 25-34 35-44 45-54 55-64

1996/1997 24 19 13 6 2

2000/2001 20 15 10 6 1

2001/2002 21 16 8 5 1

2007/2008 29 13 7 1 1
3. MEDICAL ASSESSMENT AND
INTERVENTIONS
 Evidence-based Practice Panels
(EBPP) Rating of Interventions
Recommendation Evidence Description of Category
Rating
Strongly Recommended A Improves outcomes, benefits substantially,
outweigh harms and costs
Moderately Recommended B Improves outcomes, intermediate quality of
evidence of benefits vs. harms/costs
Recommended C Limited evidence that may improve function
Insufficient- Recommended I “Best medical practice” to acquire/provide
information to diagnose/treat. Nominal cost,
no harm. Cannot make “evidence-based”
recommendation.
Insufficient- I Evidence is lacking, of poor quality, or
No Recommendation conflicting, cannot determine balance of
benefits, harm, or costs, Neutral: not for or
against the intervention.

(Hegmann, 2011)
 Medical Diagnostics (EBPP rating)
• Antibody tests (A) • Helical CT (I)
• C-reactive protein, • Electromyography (including
erythrocyte sedimentation nerve conduction studies)
rate, other inflammatory (I)
marker tests (I) • Magnetic resonance imaging
• X-ray (I) (MRI) (I)
• Arthroscopy (I) • Magnetic resonance
• Bone scanning (I) arthrography (MRA) (I)
• Computerized tomography • Ultrasound (I)
(CT) (I)
(I) = Insufficient – Recommended
(Hegmann, 2011)
 Shoulder (Rt. ant.) X-Ray

- EBPP rating: (I)

-Insufficent, Recommended
-Pain
-Tears
-Instability
-DJD
-Frozen Shoulder
Rotator Cuff Tear
 Shoulder MRI

EBPP rating (I), Insufficient Recommended

 Is an MRI needed?
MRI of Rotator Cuff in Asymptomatic
Shoulder
• Miniaci (1995),
N = 30 shoulders, 20 healthy, painfree volunteers
Grade 0- normal
Grade 1 – diffuse signal
Grade 2 – high signal within tendon, < full thickness
Grade 3 – high signal through full thickness of tendon

Conclusion: None were Grade 0 or 3

ALL (100%) had Grade 1, 23% had Grade 2 tear
Labral Tear
Medical Treatments
4. ROLE OF THE PHYSICAL THERAPIST …
INTERVENTIONS
PT … It’s More Than Exercises

(Guide to Physical Therapist Practice, 2001)

Additional Roles of the Physical Therapist in the Industry

• Pre-Employment Screens
– Can worker perform critical job tasks? Has ability?

• Worker Safety In-services

– Safe lifting, posture, body mechanics, ergonomics

• Job Site Analysis/Work Station Evaluation

– Confirms job descriptions, make recommendations

• Functional Capacity Evaluations

– Comprehensive physical exam, physical tests for job description
and non-organic signs
 PT Shoulder Exam: Impingement Tests

• Hawkins-Kennedy Test

• Painful Arc Sign

• “Giving-way” During External

Rotation Resistance (elbow at side)
Impingement was likely:
> 95% when all 3 were positive (+)
< 24% when all 3 were negative (-)

(Park et al, 2005)

PT Shoulder Exam: Rotator Cuff (RC)
 PT Shoulder Exam: SLAP (labrum) Tests
• Biceps Load test (N=75 shoulders)
Specificity = 97% If (+) pos, % you can rule in
Sensitivity = 91% If (-) neg, % you can rule out

(Kim et al, 1999)

 PT Interventions
CPT Codes within 97000 Series
 Ultrasound
CPT Code 97035 (ea 15min)
• Sound (pulsed or continuous)
– absorbed 2-5cm deep into soft tissue (ligament, tendon, fascia)

• Thermal effect
– ↑ Blood flow, speeding healing

• Non-thermal effect
– Cavitation, air bubbles to form
along cell wall affecting cell/tissue
repair, managing inflammatory
response
 Ultrasound … the Evidence
• Shoulder calcific tendonitis (Shomoto et al 2002) (Ebenbichler et al 1999)
– ↓’s size of calcification, ↑’s motion with less pain
• EBPP
– (C) Recommended for calcific rotator cuff tendonitis
– (I) Insufficient, no recommendation for: SLAP tear, Frozen
Shoulder, AC jt. sprain, shoulder instability
(Hegmann et al, 2011)
• (Nykanen 1995)
– Shoulder pain of at least 2 mo., painful arc of 40-120 degrees of
abduction
– Pulsed ultrasound, no differences in outcomes in treatment
groups.
 Electrical Stimulation (unattended)
CPT Code 97014
• NMES
– Neuromuscular electrical stimulation
• Eliciting a muscle contraction via electrical impulses
– Strength training

• TENS
– Transcutaneous electrical
nerve stimulation
– Pain control
 Electrical Stimulation … the Evidence
• EBPP (I), No recommendation for:
– Rot cuff, dislocation, SLAP tear, AC jt., Frozen Shoulder
(Hegmann et al, 2011)
• For post-op rotator cuff repair:
– NMES to infraspinatus:
• 22% increase in external rotation force (Reinold 2008)
– NMES to supraspinatus:
• At days 45 and 90
– No appreciable change in strength
– Increase in internal rotation and external rotation ROM
(Blum et al 2009)
 Iontophoresis
CPT Code 97033 (ea 15min)
• “Injection without the needle”

• Using electric charge to deliver

medicine (steroid) through skin

• i.e. Dexamethasone, neg (-)

charged, attached to electrode
over inflamed shoulder tendon
or bursa
 Iontophoresis … the Evidence
• Biceps tendonitis, (+) effects with:
– Pain, ROM, Function (Taskaynatan 2007)

• EBPP (I): Insufficient, No recommendation

– Shoulder Dislocation/Instability,
– SLAP tear
– AC joint sprain
– Frozen Shoulder
**Note subacromial injections (by physician) for impingement,
bursitis, tendinitis have a (B) rating
 Elastic Therapeutic Taping
Neuromuscular Re-education
CPT Code 97112
• “Kinesiotape”, “K-Tape”
• Cotton strip with acrylic adhesive
• Thought to:
– Facilitate muscle contraction
– Facilitate proprioception
– Inhibit Pain
– Manage edema
• Improve lymphatic drainage and blood
flow
Elastic Therapeutic Taping … the Evidence
• Immediate improvement, decreased pain with shoulder abduction
(raising out to side), but no significant difference after 6 days
(Thelen 2008)

• In baseball players, found to increase:

– Lower trapezius activity
– Posterior scapular tilt (Hsu 2009)

• EBPP (I), Insufficient

– No recommendation
 Infrared Light/Low Level (cold) Laser
CPT Code 97026
• Reduce inflammation
– Decrease vasodilation

• Reduce pain
– Stimulate beta-endorphins

• Accelerate tissue repair

– Has biological effects
– Affects mitochondria in the cell, ↑ ATP (energy)
Infrared Light/Low Level (cold) Laser …
the Evidence
• EBPP (I)- Insufficient, No recommendation (Hegmann et al, 2011)
• (Dogan et al 2010)
– Random/double blind study: Effect of low level laser in subacromial
impingement syndrome:
– Both laser and placebo demonstrated improvements (including cold
packs, exercise)
– No difference in pain, ROM, disability between groups, superior of
laser NOT demonstrated.
• (Montes-Molina 2012)
– “Interferential laser therapy in the treatment of shoulder pain and
disability from musculoskeletal pathologies: a randomized
comparative study”
• (+) Reductions in pain and disability
 Manual Therapy Techniques
CPT Code 97140 (ea 15 min)
• Includes:
– Soft tissue mobilization (muscle,
fascia)
– Joint Mobilization: passive
movements applied to tissue or a
joint in a controlled manner to
improve ROM, non-thrust in nature
(graded 1-4)
“Grade 4 joint mobilization to
right glenohumeral joint,
anteriorposterior, to assist
forward flexion, necessary to
reach overhead”
– Joint Manipulation: (HVLA) high
velocity low amplitude “thrust”
technique (grade 5)
 Manual Therapy … the Evidence
• “Manual physical therapy applied by an experienced physical
therapist combined with supervised exercise … is better than
exercise alone for increasing strength, decreasing pain, and
improving function in patients with shoulder impingement
syndrome” (Bang et al. 2000)

• Shoulder mobilization (non-thrust) with active patient movement

– Increases ROM and decreases pain (Teys et. al, 2008)

• Thoracic manipulation (grade 5, thrust)

– Rib and spine therapy for shoulder pain
– Immediate decrease in pain and increase in ROM
– No adverse affects (Strunce et al, 2009)
 Manual Therapy Ratings per:
Evidence Based Practice Panel (EBPP)
• Shoulder Dislocation/Instability
– (I) Insufficient evidence, No recommendation
• SLAP (labrum) tears (non-surg)
– (I) Insufficient evidence, No recommendation
• Rotator Cuff Tendinopathy
– (I) Insufficient evidence, Recommended
• Proximal Humeral Fractures
– (A) Strong evidence, Recommended
• Frozen Shoulder, “Adhesive Capsulitis”
– (B) Moderate evidence, Recommended

(Hegmann et al, 2011)

 Therapeutic Exercise
CPT Code 97110
• Movements and activities to improve:
– ROM
• Pulleys, self-stretching
– Strength
• Resistive bands, dumbbells,
cable column
– Endurance
• Upper body ergometer
(UBE), Elliptical
 Therapeutic Exercise … the Evidence

• Evidence Based Practice Panel (EBPP):

– (A) Strongly Recommended
• Proximal humeral Fracture
– (C) Recommended:
• Acute, subacute, chronic shoulder pain
• Post-operative care
• Rotator Cuff Tendinopathy
• Frozen Shoulder- “Adhesive Capsulitis”
(Hegmann et al, 2011)
 Therapeutic Exercise … the Evidence
Virta et al 2009
How many patients with
subacromial impingement
syndrome recover with
physiotherapy? A follow-up
study of a supervised exercise
program.
– 72 patients with SAIS
received exercise program
– 87% scored excellent (18%)
or good (69%) on UCLA
Shoulder Rating Scale
– Only 3% needed surgery
Haahr et al 2005
Exercises versus arthroscopic
decompression in patients with
subacromial impingement: a
randomized, controlled study in
90 cases with a one year follow
up.
– “Surgical treatment of rotator
cuff syndrome with
subacromial impingement was
not superior to physiotherapy
with training”
“Variations in Medical Care-It Happens
in PT Too”
(Weblog: Joe Paduda, Feb 2013)

Workers’ comp billing practices b/t settings:

• Corporate and private PT centers bill for more visits and more units
per episode than other practice settings

• Corporate physical therapy clinics billed for a higher proportion of

interventions supported by evidenced-based guidelines

• Occupational Medicine and physician offices billed a higher

proportion of those interventions generally not supported by
evidence-based guidelines.

(Beattie et al 2013)
 Rotator Cuff Surgery Protocol
(General)

• Phase I, Immediate Post Surgical (Weeks 1-4)

– Goals
• Protect the repair
• Wear abduction pillow/sling all the time!
• Increase PROM (passive!)
• Control pain, inflammation
• Prevent muscular inhibition
• Become independent with ADLs

• 52% more noncompliance with immobilization

and physical therapy protocol if have a WC
claim (Cuff 2012)
 Rotator Cuff Surgery Protocol (cont.)
• Phase II, Protection/Active Motion
(Weeks 5-10)
– Allow healing, ↓ stress
– NO LIFTING
– D/C sling
– Restore full PROM
– AAROM (active assistive)
– AROM (active)
– Scapular motion  
 Rotator Cuff Surgery Protocol (cont.)
• Phase III, Early Strengthening
(Weeks 10-14)
– Goal Full AROM (Active)
– Lifting 5 lb. max
– No heavy lifting
– No overhead lifting
– Low-level functional activity
– Resistive exercise
• Resistive bands, cable column 
free weights
 Rotator Cuff Surgery Protocol (cont.)

• Phase IV, Advanced Strengthening

(Weeks 16-22)
– Maintain full ROM
– Improve muscular strength, power,
endurance
– Gradual return to full functional
activities
• 6 and 12 month “Rule”
• 6 months to have the motion
• 12 months to have the power to use
the motion
Should PTs Utilize an Accelerated Protocol?
• Duzgun et al, 2011
– Started AROM at post-op week 3
(vs. week 6)
• Improved DASH scores at
weeks 8 and 16
• Reduced pain, increase in
function in 8-12 weeks
• DASH scores equal to ‘slow’,
typical protocol by week 24
(6 months)
• Souser et al, 2012
– Early manual mobilization
• 6 weeks post-op, incr. ROM
6 months, no difference in
quality of life vs. control
group
• Lee et al, 2012
– Manual Therapy 2x/day,
unlimited self PROM
• Improved ROM and function
at 3 months post
• But, function = to control
group at 6 months
• Re-tear rate higher in
accelerated group 23% vs.
8.8%
“Must be patient with the
patients …
we can only do so
much.”
 5. FUNCTIONAL
OUTCOME MEASURES
 Functional Outcome Measures
• “Functional assessment scores (and comparisons to prior
assessment scores) from tests and measurements validated in
the professional literature that are appropriate for the
condition/function being measured”

• Completed at initial evaluation, D/C, and at other intervals

• Allow to document functional progress or lack of it

(http:www.cms.hhs.gov/transmittals/downloads/R63BP.pdf)
 “DASH” Disabilities of the Arm,
Shoulder, and Hand
• Utilized for UE musculoskeletal disorders
• 30 items
• 11 item QuickDash was also developed
• Lower score is ideal
– 0% least ‘disabled’ to 100% max ‘disabled’
– 10 point improvement to show meaningful progress
Item 23. It didn’t It It limited It limited I wasn’t
limit limited them them a able to do
them them moderately lot them
slightly
Last week, were your
work or normal activities
limited due to your arm, 1 2 3 4 5
shoulder or hand
problem?
 Is the “DASH” Evidence-based?
Cross-sectional and test-retest reliability of the
DASH and QuickDASH were similar. (Gummesson 2006)

“… can be used as a ‘surveillance’ tool in the working

population” (Fan et al 2008)
 “PSS” Penn Shoulder Score
• Self report:

• 100 point scale

• Higher score is ideal
• Evidence: “PSS is a reliable and
valid measure for reporting outcome of patients with
various shoulder disorders” (Leggin 2006)
“SPADI”, Shoulder Pain And Disability Index
• 13 items
– 5 pain, 8 disability
– Score transformed to 100
– Higher score = greater impairment or disability
• Reliability—originally poor
• Validity—compares well with other outcomes measures
geographically (Breckenridge 2011)
• “… does not appear to strongly reflect occupational and
recreational disability” (Heald 1997)
6. RETURN TO WORK (RTW) STRATEGIES
“Just because I HAVE pain doesn’t mean
I am IN pain.”
 Returning-to-Work
• Work simulation (lift, reach, push, pull)
– Get job description in the hands of the lead PT!
• Work conditioning
– Strength, Flexibility, Cardiovascular, Functional Stabilization, Material
Handling, Job Simulation
– 3-5 days/wk, 2-4 hrs/session
*Earlier RTW in patients if off work > 2 mo.
• Work hardening
– 5 days/wk, 2-8 hrs/session
*Earlier RTW by 52% in patients off work > 4 mo.
• PT involved in on site transition
• PT follow up once patient integrated

(Lechner 1994)
Successful Outcomes…
 “Key” Points to Take Home
• Evidence-based Practice … “We’re getting there”
– Lacking in many areas of diagnostics and many interventions …
we need to continue to research!
• PTs
- Are PTs in your network manual therapists being “hands on?”
- Using outcomes measures? Goal directed?
- Can they tell you what interventions they perform?
- Have you integrated the PTs in the work comp system as part of
the team?
• Patients
– Must actively participate with exercise, functional progression,
and the goal making process
• Early referral to PT may achieve better outcomes
Thank you …
 References:
Bang M, Deyle G. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther 2000; 30(3):126-137

Beattie Paul F. et al. Differences Among Health Care Settings in Utilization and Type of Physical Rehabilitation Administered to Patients Receiving Worker’s Compensation for Musculoskeletal Disorders. Journal of
Occupational Rehabilitation 2013: http://link.springer.com/article/10.1007/s10926-012-9412-y/fulltext.html

Bergason Adam G, et al. Effects of Platelet-Rich Fibrin Matrix on Repair Integrity of At-Risk Rotator Cuff Tears. Am J Sports Med; Feb 2012 vol. 40 no. 2; 286-293.

Blum K et al. Repetitive H-wave device stimulation induces significant increases in the range of motion of post operative rotator cuff reconstruction in a double blinded randomized placebo controlled human study.
BMC Musculoskeletal Disord 2009;10(132)

Breckenridge JD et al. Shoulder Pain and Disability Index (SPADI). J Physiother 2011;57(3):197

Catapang Gerry. Cut the Claims [Industrial Rehab]. ADVANCE for Physical Therapy & Rehab Medicine. July 9 2012, p.22-28

Cuff DJ et al. Prospective Evaluation of Postoperative Compliance and Outcomes after Rotator Cuff Repair in patients with and without workers’ compensation claims. Journal of Shoulder and Elbow Surgery
2012;21(12):1728-1733.

Current Procedural Terminology (CPT®) copyright 2008 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association.

Department of Health and Human Services (DHHS). Centers for Medicare and Medicaid Services. Subject: Outpatient Therapy Cap Exceptions Process for the Calendar Year (CY) 2007.
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R63BP.pdf

Dogan SK et al. The effectiveness of low laser therapy in subacromial impingement syndrome: a randomized placebo controlled double-blind study. Clinics 2010;65(10):1019-1022.

Duzgun I et al. Comparison of slow and accelerated rehabilitation protocol after arthroscopic rotator cuff repair: pain and functional activity. Acta Orthop Traumatol Turc 2011; 45(1): 23-33

Ebenbichler GR et al. Ultrasound therapy for calcific tendinitis of the shoulder. N Engl J Med 1999; 340(20):1533-1538.

Fan Z. Joyce et al. Assessing Validity of the QuickDASH and SF-12 as Surveillance Tools Among Workers with Neck or Upper Extremity Musculoskeletal Disorders. Journal of Hand Therapy Oct 2008;21(4):354-365.

Guide to Physical Therapist Practice. Second Edition. American Physical Therapy Association. Phys Ther. 2001 Jan;81(1):9-746.

Gummesson Christina, The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskeletal Disorders
2006, 7:44

Haahr JP et al. Exercises versus arthroscopic decompression in patients with subacromial impingement: a randomised, controlled study in 90 cases with a one year follow up. Ann Rheum Dis 2005; 64(5):760-
764

Heald, Susan L. et al. The Shoulder Pain and Disability Index: The construct validity and responsiveness of a region-specific disability measure. Phys Ther; Oct 1997(77)no.10;1079-1089.

Hearon, B. F. Optimal Management of Upper Extremity Orthopaedic Problems.

Hegmann KT, editor(s). Occupational medicine practice guidelines. Evaluation and management of common health problems and functional recovery in workers. 3rd ed. Elk Grove Village (IL): American College of
Occupational and Environmental Medicine (ACOEM); 2011. p. 1-297. [1977 references]

Hsu YH et al. The effects of taping on scapular kinematics and muscle performance in baseball players with shoulder impingement syndrome. J Electromyogr Kinesiol 2009;19(6):1092-1099.

Interactive Guide to Physical Therapist Practice by American Physical Therapy Association. 2003. ISBN:978-1-887759-87-8. DOI : 10.2522/ptguide.978-1-931369-64-0

Kim SH, et al. Biceps load test: a clinical test for superior labrum anterior and posterior lesions in shoulders with recurrent anterior dislocations. Am J Sports Med. 1999;27:300-303.
 References:
Lane, Kathy. OSHA’s Top 10 Violations of 2012 Announced at National Safety Council Congress and Expo, Oct 23 2012. http://www.nsc.org/Pages/OSHA-Top-10-Violations-for-2012-announced-at-NSC-Congress--
Expo.aspx

Lechner DE. Work Hardening and Work Conditioning Interventions: Do They Affect Disability? Physical Therapy May 1994;74(5):471-493.

Lee BG et al. Early Aggressive Rehabilitation Outcomes Following Arthroscopic Rotator Cuff Repair. Arthroscopy 2012 Jan;28(1)34-42.

Leggin BG. Penn Shoulder Score: Reliability and Validity. filter your current search Find all citations in this journal (default).
Or filter your current search
The Journal of Orthopaedic and Sports Physical Therapy [2006, 36(3):138-151]

Miniaci Anthony, Magnetic Resonance Imaging Evaluation of the Rotator Cuff Tendons in the Asymptomatic Shoulder, Am J Sports Med March 1995 vol. 23 no. 2 142-145

Mohtadi NG, Hollinshead RM, Sasyniuk TM, Fletcher JA, Chan DS, Li FX, A randomized clinical trial comparing open to arthroscopic acromioplasty with mini-open rotator cuff repair for full-thickness rotator cuff tears:
disease specific quality of life outcome at an average 2-year follow-up. Am J Sports Med 2008; 36(6): 1043-1051

Montes-Molina R. et al. Interferential laser therapy in the treatment of shoulder pain and disability from musculoskeletal pathologies: a randomised comparative study. Physiotherapy 2012;98(2):143-150.

Murrell GA, Walton JR. Diagnosis of rotator cuff tears. Lancet 2001; Mar 10;357(9258):769-70.
Osteras H. Clinical and MRI findings after high dosage medical exercise therapy in patients with long lasting subacromial pain syndrome: A case series on six patients. Journal of Bodywork and Movement Therapies.
Vol 14(4);Oct 2010;352-360.

Nykanen M. Pulsed ultrasound treatment of the painful shoulder, a randomized double blind, placebo-controlled study. Scand J Rehabil Med 1995;27(2):105-108.

Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG, Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am. 2005 Jul;87(7):1446-55.

Reinold MM, et al. The effect of neuromuscular electrical stimulation of the infraspinatus on shoulder external rotation force production after rotator cuff repair surgery. Am J Sports Med 2008;36(12):2317-2321

Restrepo T, Shuford H, Thinking About an Aging Workforce-Potential Impact on Workers Compensation, NCCI Research Brief, May 2005

Restrepo T, Shuford H, Workers Compensation and the Aging Workforce, NCCI Research Brief, Oct 2012

Shomoto K et al. Effects of ultrasound therapy on calcificated tendinitis of the shoulder. J Jpn Phys Ther Assoc 2002;5(1)7-11.

Souster M et al. COA Early ROM rehabilitation following rotator cuff repair provides no additional benefit. Ortho Evidence 2012; Dec 6.

Strunce JB et al. The Immediate Effects of Thoracic Spine and Rib Manipulation on Subjects with Primary Complaints of shoulder pain. J Man Manip Ther 2009;17(4):230-236.

Taskaynatan MA et al. Effects of steroid iontophoresis and electrotherapy on bicipital tendonitis. J Musculoskelet Pain 2007;15(4):47-54

Thelen MD et al. The clinical efficacy of kinesio tape for shoulder pain: a randomized, double blinded clinical trial. J Orthop Sports Phys Ther 2008; 38(7):389-395.

Teys P. et al. The initial effects of a Mulligan’s mobilization with movement technique on range of movement and pressure pain threshold on pain-limited shoulders. Manual Therapy. 2008 Feb 2008; Vol 13(1); 37-42.

U.S. Bureau of Labor Statistics, Nonfatal Occupational Injuries and Illnesses Requiring Days Away from work, 2011. Released Nov 8 2012, www.bls.gov/news.release/osh2.nr0.htm

Van der Windt DAWM, Physiotherapy or Cortisone Injection for Shoulder Pain? Ann Rheum Dis 2003;62:385-387 doi:10.1136/ard.62.5.385

Virta L et al. How many patients with subacromial impingement syndrome recover with physiotherapy? A follow-up study of a supervised exercise programme. Adv Physiother 2009;11(3):166-173.