Use of a surgical referral algorithm within a standardized shoulder physical therapy program to assist clinical decision-making.

Abstract

Determine (a) utility of a shoulder referral algorithm, (b) patients improving ≥15% on the Western Ontario Rotator Cuff(WORC) score with standardized Physical Therapy(PT) +home exercises, and (c) presenting characteristics among PT-Only, PT + Surgical Consult and Surgery participants. Prospective cohort study of patients 30-65 years old with shoulder pain. A standardized PT program assessed pain, ROM, strength and exercise tolerance (i.e., referral algorithm) at 2-, 6- and 12-weeks to determine if a surgical consultation might be beneficial. A blinded research assessor evaluated pain, ROM, strength and WORC score at 6-, 12-weeks and 6-months. The proportion improving WORC scores ≥15% and group differences were also evaluated. 32/128 (25%) participants underwent consultation with 16 (12.5%) undergoing surgery. WORC scores improved ≥15% by 12-weeks in most PT-Only/PT + Surgical Consult participants (<i>n</i> = 77[70%]) and was maintained at 6-months. Surgery participants used more NSAIDs (<i>p</i> = 0.01), injections (<i>p</i> = 0.002) and trended to higher opioid use (<i>p</i> = 0.06). PT + Surgical Consult/Surgery participants (<i>n</i> = 16/32; 50%) knew diagnostic imaging results more than PT-Only (<i>n</i> = 26; 31%) (<i>p</i> = 0.02). Surgery participants presented with worse pain, ROM, strength and WORC scores than PT-Only (<i>p</i> < 0.05). The algorithm identified those with worse symptomology (25%), 50% of whom underwent surgery. WORC scores improved ≥15% in most participants (70%). Presenting characteristics were significantly worse between PT-Only and Surgery participants.