March 2021 PULSE

MARCH 2021

MARCH MADNESS... YOU’RE NOT KIDDING! March Madness is coming back in 2021! As with most events emerging from COVID-19 cancelations, it will look and feel different. The Men’s Basketball Tournament will start March 18th and all games will be played in Indiana, while the Women’s Basketball Tournament starts March 21st with all games being played in and around San Antonio, Texas. The NCAA is attempting to keep the events as safe as possible by limiting attendance, keeping travel to a minimum and performing extensive testing before, during and after the games.

In early February, basketball, gymnastics and swimming events began.

There are restrictions and limitations – rules that make participation as safe as possible, which, much like this year’s March Madness, make the events feel different. Word on the streets is that the high school athletes are grateful to at least have games, meets and matches to look forward to. I don’t blame them – it’s been a long year!

When I consider the logistical challenges of 2021 sporting events, I marvel at the creativity and commitment being put forth by PTSMC’s Athletic Trainers for CT high school sports! When the CIAC postponed the winter athletics season, the ability of our Athletic Trainers to provide contracted services in the “traditional” way ended. At the time of the announcement, it looked like keeping our trainers connected to the communities and students we serve was in peril.

My thanks to our Athletic Trainers: Jenna Bouffard Sam Donahue Bethany Grady Eric Lanese Liz Saunders Chelsea Searles

With strong leadership provided by Caty Halpin, our Sports Medicine Coordinator, the entire Athletic Training staff at PTSMC successfully pivoted to provide services virtually!

These professionals have demonstrated commitment and creativity, improving the quality of the lives of their student-athletes, parents and coaches by providing unmatched experiences, clinical excellence and lifelong relationships.

Starting in early December and continuing through much of January, PTSMC’s Athletic Trainers provided injury evaluations, exercise programs, and assisted student athletes – along with their parents and coaches – in navigating health care decisions. Each week they offered virtual “office hours” and provided content to coaches and student athletes. Training programs included strength and conditioning, stretching sessions and Yoga. Our Athletic Trainers also provided educational sessions on nutrition, proper exercise technique, and mindfulness. They worked with individuals and they worked with entire teams.

This is another example of how the PTSMC mission stands the test!

Ron Buchetto Heather Feiner Caty Halpin Hailey Lugo Greg Schlossinger Hunter Warner

A little more than a year ago, this approach to providing Athletic Training services might have a appeared to be its own kind of madness.

Their efforts to continue providing world-class service in their communities has been remarkable and deserves March Madness-level applause. Thank you for helping keep PTSMC connected to communities we serve!

Alan

Patient Trends New Patients per Month

Please provide your feedback As Alan talked about in his mid-month communication, the PULSE is a vital medium to communicate what is happening throughout the company.

Visits per Month

We want to hear from you about what you find most useful, what you enjoy reading, and what you don’t think is necessary.

If you haven’t already completed the survey in Alan’s email, please do so! It is also in the March 2021 PULSE email.

Blue = Actual | Orange = Budgeted

IN THIS ISSUE

Clinician’s Corner by Sean Walsh An Update on Relevant Data & Expected Timeline Following Arthoscopic Rotator Cuff Repair The Extra Mile by Kristen Forster Digital Intake Is Here 2020 Clinic NPS Scores HR Buzz Wellness Program Self Love Initiative #GetMoving March On Challenge PICO Project from Orthopaedic Residents

StriveHub Fab 5 “The PTSMC Orange therapists and staff are attentive, focused, caring and proactive in their instruction and support.

I am indebted to them, especially to Anthony Ciaburri, for helping me recover my active and pain-free life!”

- Orange “I’m a return client. After major surgery caused complications I found myself needing to rebuild the damage. I know from experience that the team at Essex PT & Sports Medicine Centers are extremely qualified. I’m happy to report that I’m making progress already.” - Essex “Clients are given the tools to keep improving at home. I also like that we are brought in twice a week to reinforce to continue the exercise. Being in the environment alone makes you want to do your exercises correctly and thoroughly.

The accountability happens when you return and repeat the program designed for your individual needs.” - Guilford “I would highly recommend PTSMC! With the knowledge and encouragement of the therapists, I am sure I will meet my goals to recover fully from surgery. And, I cannot say enough about every member of the staff being friendly and helpful no matter what is needed.” - Avon “Been coming here for years. Staff is friendly, knowledgeable, organized and professional. Always see results from my PT. I would also add personable and interested to my description of the staff.

In a world where people give less and less personal service, the folks here take a personal interest in you which kinda makes you feel like family.” - Southington

CLINICIAN’S CORNER

AN UPDATE ON RELEVANT DATA AND EXPECTED TIMELINE FOLLOWING ARTHROSCOPIC ROTATOR CUFF REPAIR

By Sean Walsh, PT, DPT Physical Therapist at PTSMC Waterbury Rotator cuff repair surgeries have an increased incidence within the past decade to over 15 interventions per 103 individuals accounting for over 270,000 surgeries annually.1 Likewise, the prevalence of meaningful tears reported is varied, but increases particularly in the later decades of life. More specifically around 15–20% of 60-year-olds, 26–30% of 70-year-olds, and 36–50% of 80-year-olds would have positive findings via MRI.1 This points to the possibility that degeneration of the rotator cuff increases throughout the lifespan. Additionally, it has been reported that the structures most commonly involved include the supraspinatus, implicated in 75% of positive studies, and the infraspinatus, implicated in 20% of partial rotator cuff tears; while the subscapularis is rarely affected in isolation.2 Furthermore, there is a proportion of population of those with rotator cuff tears that does respond meaningfully to scapular stabilization and control exercises. Observed post-exercise program outcomes include increased internal and external range of motion, decreased end range rotation pain, and associated improvement in isokinetic rotation strength.2 Despite this presentation and the potential for conservative management, there are many instances in which arthroscopic surgery is necessary.

Research throughout the years has identified multiple factors associated with post-surgical healing including patient age, preoperative tear size, muscle atrophy, fatty infiltration, and rehabilitation methods.3 In a world where arthroscopic surgery has become the preferred method, however, previous research published in 2015 found that there was no difference in failure timing. That is to say that 40% of failures occurring within 12 months, do so despite the progress in arthroscopic procedures.1 It is important to also consider that when stratified for tear size, failure to heal rate for small, medium, and large tears has been reported at 34%, 36%, and 47% respectively.1 Furthermore, age is a meaningful predictive factor for tear size even when considering additional covariates. Subsequently tear size classification as “massive” is itself an independent predictor of healing.1 When three tendons are involved, an observed survival rate of 57.9% has been reported.3 This is compared to an 88.4% survival rate when only two tendons are involved; and that rate continues to improve with smaller tears.

On the surface, this all seems to make some sense and perhaps does not offer much to your clinical picture; although I hope that it does. However, this is not where the research stops. As long ago as 2014 as reported on by Kim et al., partial healing without retear occurred at a rate of 39.3% within the first three months and confirmed retearing occurred at 6.6% during the following nine months.3 In a prospective study of a homogenous group undergoing rotator cuff repair, the retear rate was calculated to be 15.3%, with a 15% retear rate when a traumatic mechanism occurred, and a slightly higher 16% retear rate in setting of progressive chronic presentation.3 All retears observed in this study occurred within 6 months of surgery.

While stratifying further, 59% of retears occurred in the first 3 months, 22% between three and six months, and another 19% occurring after six months from the date of the operation.3 As you may be able to guess, the post-operative functional scores were significantly lower for retorn rotator cuffs with retears than for those intact.

So, what’s the take-home here? Firstly, it has simultaneously been reported that most retorn rotator cuffs still had considerable improvement in post-operative scores compared to pre-operative scores.3 However, the “critical period” for tendon retears following arthroscopic repair is perhaps much longer than we as clinicians typically give it credit for. Based on the researchers’ findings, there is a non-negligible risk of retear that exists for as long as six months following surgery. Clinically it becomes important that we remain observant and reflective of our type, volume, and rate of increase of loading while managing this common population.

1. Rashid MS, Cooper C, Cook J, et al. Increasing age and tear size reduce rotator cuff repair healing rate at 1 year: Data from a large randomized controlled trial. Acta Orthop.

2017;88(6):606-611.

2. Jinhwa Jung, Kihun Cho, Jaeho Yu. Effects of Scapular Stabilizing Exercise in Patients with Partial-thickness Rotator Cuff Tear. J Phys Ther Sci. 2012;24(11):1173-1175.

3. Barth J, Andrieu K, Fotiadis E, Hannink G, Barthelemy R, Saffarini M. Critical period and risk factors for retear following arthroscopic repair of the rotator cuff. Knee Surg Sports Traumatol Arthrosc. 2017;25(7):2196-2204.

CLINICAL EXCELLENCE Upcoming Courses INTERNAL COURSE

PTSMC SPONSORED COURSE

Lumbar - 8 hour Saturday April 24, 2021 PTSMC Guilford Taught by Brian Greer & Melissa Boutagy *Participation limited

Myopain Trigger Point Dry Needling (TDN) June 2021 Location TBD

The DOCS Program would like to recognize and give a sincere congratulations to our most recent graduate, Andrew Perazella, New Haven PT! PTSMC values and is built upon the foundation of clinical excellence; Andrew lives up to this part of our mission statement every day.

Andrew began the DOCS Program in November 2018, completing mentorship in his first year, and most recently completing the required (in-person) Internal Courses in October 2020.

Andrew was one the first DOCS members to transition two required courses to Medbridge, and his completion of the Return to Sport and the TNE Medbridge courses sealed his DOCS Program graduation.

Email Mallory at coned@ptsmc.com for all sign ups or questions.

NPS Year in Review!

Total Responses 5,279 6,663 5,417

Promoters 92% (4,857) 94% (6,249) 95% (5,146)

Passives 6% (312) 4% (315) 4% (216)

Middletown Naugatuck New Haven New London New Milford Newington Orange Plainville Simsbury

95% 94% 87% 94% 94% 86% 95% 92% 100%

Detractors 2% (105) 2% (99) 1 % (54)

Congratulations to Recent DOCS Graduate!

NPS Score 90% 92% 93%

We asked Andrew what the most influential part of the DOCS Program was and he said, “Having guidance from multiple, seasoned mentors with their own skills & treatment approaches has Even during the COVID-19 pandemic, we had an awesome year for NPS surveys. Although the number of been the most influential for me. The advice and responses decreased, we still had a higher percentage of promoters, a lower percentage of detractors, and a tutelage I've received has been very helpful and higher NPS score! Each clinic reached the benchmark of an NPS score above 85% - amazing! Below is each clinic’s has shaped me to be a better clinician.”

NPS score for 2020. Congratulations to those who reached the PTSMC goal of a 95% or higher!

2018 2019 2020

Avon Branford Danbury East Hampton Essex Fairfield Groton Guilford Lock Street

91% 89% 98% 96% 90% 96% 97% 91% 88%

Southbury Southington Wallingford Waterbury Watertown West Hartford Westbrook Wethersfield Windsor

STUDENT PROGRAM UPDATE This month we’re pleased to welcome Khamille Turnage, from Hampton University. She begins her final affiliation in New Haven working with Andrew Perazella and Russ Woodman.

A special thank you to Guilford, Wallingford and Westbrook clinics who will be hosting D2 QU students for ICE (Integrated Clinical Experiences) beginning in March.

And thanks to the Avon crew for their continued work with UHart's ICE program.

95% 93% 95% 95% 94% 94% 92% 89% 93%

Andrew’s next personal professional steps are to, “become more adept at treating vestibular/ concussion type patients as well as further hone my skills as an outpatient orthopedic PT with eventual pursuit of an OCS certification.”

Awesome goals Andrew! We again congratulate your graduation from DOCS and commend your hard work and being a pioneer of the new virtual requirements.

HUMAN RESOURCES

NEW EMPLOYEES

VACATION REMINDER

Reminder to use your vacation time before your anniversary date!

Vacation time must be used within an employee’s anniversary year. Employees may use vacation time prior to accrual at the director’s discretion.

Full Time Part Time

Up to 40 hours Up to 20 hours

D4DS AND GOALS & OBJECTIVES

All required employees should be nearing or have completed 2020 D4D process.

Nate Anderson, Wallingford PT Aide

Travis Franco, Essex PT Aide

Matt Gazaille, Windsor PT Aide

Megan Gilbey, Avon PT Aide

Employees’ fillable Performance Area Forms and 2021 Goals and Objectives will be uploaded into Human Resources To view log in to Paychex Flex and click on Under Personal Information click on Employee Documents & Links

TIMESHEET COMPLETION

NOT PICTURED

If you have not already started to use the “new view” please start soon! Paychex Time and Attendance classic view will be going away shortly - date to be determined. You will be receiving video instructions on how to complete your timesheet under the new view during the month of March. For those who have been using the mobile app to complete their timesheet, the layout is very similar. A visual with brief instructions is outlined below: • Once you are in Time & Attendance it defaults to the overview tab • Click on Edit to view the pay period and enter your hours worked • Complete your hours for the day and click on submit button at the top • Click approve button at the end of the pay period when your timesheet is completed

Danny Silva Waterbury PT Aide

Virginia Katz, Westbrook PT Aide Cara McCausland, Wallingford PT Aide Rachel Williams, Southington PT Aide

CURRENT JOB OPPORTUNITIES

RAFFLE WINNER!

Congratulations to Tracy Caligiuri, Waterbury PSA, who is the winner of the HR Buzz raffle that was in the February PULSE. Tracy received a $25 gift card!

Physical Therapist Waterbury

Physical Therapy Aide Branford Fairfield Westbrook

Patient Services Coordinator Glastonbury Guilford

Athletic Trainer Essex New London

Check www.PTSMC.com/job-openings for our most up-to-date postings, and feel free to share!

Call Jenn or email at Jenn.Detlefsen@ptsmc.com for PT Aide positions.

Call Karen or email at karen.havlicek@ptsmc.com if you are interested in another position.

The

Extra MILE

By Kristen Forster, Director of Operations

Digital Intake is Here!

It’s official! ALL PTSMC and PT for Life locations have officially transitioned to Digital Intake. A BIG shout out to Alison Pearce for her hard work to reach this goal!

What exactly is captured in Digital Intake?

• Emergency Contact • Referral Source • Medical History • Patient Symptoms • Pain Levels • Medications List • Patient Goal for Treatment • Notice of Privacy Practices • Signed Consent for Care and Treatment So, how does this serve our patients?

• Patients can complete their “paperwork” at their convenience.

• It’s EASY! The digital intake is adaptable to be completed on both computers and mobile devices. It can easily be sent via email or text.

• Once completed, it automatically flows right into eDocs in WebPT! This means you can see everything ahead of time and be better prepared for the patient’s visit.

• Patients arrive and are ready for treatment. NO MORE WAITING = Happy patients!

This is an exciting step for PTSMC and our patients. If you have any questions or feedback to share, please reach out to Alison at Alison.Pearce@ptsmc.com.

Congratulations on Your Promotion!

Congratulations to Lauren Mariotti, who has been promoted to Patient Services Administrator in our Watertown clinic. Lauren started with PTSMC in Watertown in January 2018. Bringing strong customer service and administrative skills to the role, Lauren adjusted quickly to healthcare. Mentored under Kate Carlson, former Patient Services Administrator in Watertown (Kate transitioned to the Administrative team in a part-time remote role in order to spend time with her daughter), Lauren has stepped up her leadership, payer acumen and strong organization skills. Partner & Director of the Watertown clinic, Pete Catuccio commented, “Lauren was meant for this role. Honestly, she came into the PSC position on the quiet side with a lot to learn about healthcare and PTSMC. She hit the ground running and is now depended on for keeping me and the staff informed about important changes, maintaining the flow of the clinic and being a ‘go to’ person for staff. Early on I was afraid of being so loud and emotional and her being so quiet but she has taken everything in stride and has excelled! I am thrilled to be part of her growth and development.”

In her free time, Lauren enjoys hiking trails and reading a good book. She is particularly excited about her new role because she has the opportunity to take on more responsibilities and to continue to grow within the organization. She plans to continue to learn new skills and to continue to strive to be an asset to the clinic and her colleagues.

MARCH BIRTHDAYS Donna Baribault Lindsey Scianna Renee Gallant Alison Pearce Pat Kinsella Jorge Paucar Olivia Schaub Tom Kirsch Mackenzie Anderson Victoria Arlia Danielle Pilgrim Emma Anderson Zack Currie Lauren Jameson Jared Schiffer Julianne Balavender Dave Lawrence Sona Pinela Kevin Howard Katie Newton Danielle Jaffer Nancy Chilson Emma Hart Mikayla Raffone Dana Earle Summer Adams Shelby Howe Sophia Shea Karin Larsen Jenna Bouffard Amanda Baldwin Jamie Collimore Heather Feiner Ted Raczka Annemarie Gigante Brooke Uliano Dominique Riley Gabby Didiano Connor Doherty Jackie Beltram April Alver

1 1 3 4 4 4 6 8 8 8 10 12 12 12 13 13 13 13 14 14 15 16 17 17 17 18 18 18 19 21 21 23 24 26 26 26 26 27 28 30 30

Admin Watertown New Haven Admin Guilford New London Simsbury Avon Essex Wallingford New Milford Groton Guilford New Haven Wallingford Admin Admin New Haven Orange West Hartford Southington Avon Groton New Haven Southington Guilford Simsbury Watertown Groton Watertown Westbrook Southington Admin Branford Fairfield New Haven Orange Middletown Wethersfield New Haven West Hartford

MARCH ANNIVERSARIES

Betsy Holt

PSC

Simsbury

PTSMC Happenings!

Rob Bass (left), Middletown Physical Therapist sent in a testimonial with his patient Dave (right).

Rebecca Petrosino (left), Fairfield Partner & Director, pictured with Dr. Christina Allen, Sports Medicine Division Chief and Yale Head Team Physician, who raved about Rebecca’s treatment.

CONGRATULATIONS!

Andrew Kalach, Fairfield Physical Therapist, sent in an adorable testimonial from one of his youngest patient’s parents.

Debra Philcox, Naugatuck PSC snapped a selfie when participating in the Self-Love Challenge and showing off Naugatuck’s Valentine’s Day decorations.

Avon celebrated Valentine’s Day by dressing in pinks and reds!

SoCIAl Media Sensation Kailey Hanks & Natalie Swanson , Lock Street Physical Therapist & PTA

Ryan Balavender, Director of Facilities, welcomed Clayton George Balavender on January 28, 2021.

Kailey and Natalie (pictured) sent marketing pictures and a description of a stretch for our “Show Your Body Some Love” initiative.

Make sure to check out the graphic on our Facebook, Instagram, and Twitter accounts @ptsmc.

PTSMC Wellness CalendaR How We Practiced Self-Love Earlier in February, the Wellness Program ran a Self-Love Challenge. Each day, participants were challenged to practice self-love in a new way. Sometimes the hardest part of practicing self-love is knowing HOW. So, we wanted to share how 30+ different PTSMC members practiced, to inspire you to try it!

Responses to learning what self-love is and why it is important: “Self compassion helps you strengthen your relationship not only with yourself but with other people as well which is very important.”

“Self compassion is a skill that requires practice.”

“It builds resilience and freedom; allowing you to move past self doubt, and therefore leading a more enriched life.”

“Treat myself like I would treat a friend during a hard time!! I would never treat a good friend the way I treat myself. Treat myself with kindness and acceptance. I don’t need to earn kindness and acceptance, my existence is deserving enough.”

Examples of positive affirmations: I am good at multi-tasking. I am like my fashionista side. I am able to help people learn new things. I truly care about people’s happiness and their wellbeing. I am intelligent. I love that I can run long distances. I enjoy helping and making people feel better. I am a great clinician. I am good at carpentry.

Examples of how meditation felt: “Didn’t realize how tense my body was!”

“It made me realize I need to do this way more often.”

“Love to take the time to stop and shut everything out. It's so refreshing.”

“I had a much better night’s sleep!”

“Meditation before I study, getting mentally ready and focused with some time to breath.”

Examples of personal love letters written to yourself:

March #GetMoving Challenge April Financial Wellness

Mar. 7 - Apr. 10 New Date!

Month of April

#GetMoving

MARCH ON CHallenge

Making your health a priority in 2021 starts at the most basic level- being active. Moving your body benefits your physical, mental, and, in this case, social wellness too! Join our #GetMoving March On Challenge to be connected, motivated, and have fun getting active with other PTSMC go-getters.

New Date!

The March On Challenge runs for 5 weeks: Sunday, March 7th – Saturday, April 10th The Challenge: Get active for 30+ minutes for 20 of the 35 days and you will earn a reward. Hungry for a bigger challenge? Achieve 30 or more days of activity and you’ll earn an additional prize!

There will be opportunities to earn bonus days for participating in well-being themed challenges, no burpees needed.

Examples of how to move your body: Peloton, Jillian Michaels HIIT, 4 miles on the treadmill, upper body with weights, Yoga, lunchtime walk, barre class, walked 4 miles, ran 3+ miles in the sloppy roads, tai chi/yoga/pilates work out via zoom Examples of reading for pure enjoyment: Books- Fiction and Non-Fiction Race Matters The Intelligent Investor Chasing the Night How to Think Like a Monk

Sorry I'm late, I Didn't Want To Come Where Do I Begin by Elvis Duran Super Life Chosen Ones

We will be using the Slack app to submit activities and support each other over the five weeks. Each DAY you #GetMoving, post your activity in the group and it will count towards your running total. Your post can include a picture of your activity, you, your watch, your view, your dog, or you can just send a description of your activity, no picture required. Other participants will be able to see your post, like the post and support you. No one outside of the group will see the messages. The Slack group will also be where you get the latest challenge information, updates, and fun activities.

Articles Wrist anatomy and biomechanics Exercise training in heart failure in JAMA Living with pathological narcissism: a qualitative study Cook’s Illustrated

How to sign up: Email Mallory at the PTSMC Wellness Program email- Wellness@ptsmc.com. Signups will run through March 6th. Once the group is established, there will be an email sent out with more detailed instructions for participants.

Examples of Wellness goals set related to Physical Health, Mental Health and Self-Love: Drink more water, Meditate on a regular basis, Stay positive regardless of circumstances, I will find time to get my heart rate up every day, I am dedicating at least half hour every day for myself - reading, listening or doing whatever that is for me, Add more fish and vegetables to my menu, Spend 5-7 mins breathing and meditating before I start my workday, Each Sunday – reflect back on the week and have 3 affirmations.

If you participated in the #GetMoving A Festive Fall Challenge and you bring a PTSMC buddy with you to the March On Challenge, you AND your buddy will receive a bonus day from the get go!

Examples of where to take a gratitude walk: Neighborhood, reservoir, on a run, walking the dog, River Road in Mystic, in the woods, around New Haven Want to try the Self-Love Challenge yourself? Refer back to emails from Wellness@ptsmc.com for full details and options for each practice.

ORTHOPAEDIC RESIDENCY PROGRAM PICO PROJECT: UPPER EXTREMITY

By: Meghan Blanusa, Naugatuck Physical Therapist, and Tom Mango, New London Physical Therapist Over each 3-month semester, the residents complete a PICO Project - one for each area of the body.

PICO is a format used in evidence-based practice to answer a question regarding the intervention or clinical question using an extensive literature search.

PICO stands for Patient/Problem, Intervention, Comparison, Outcome.

P: Men and women ages 40-60 years old who present with decreased mobility, decreased function and increased pain of their shoulder without mechanism of injury I: Manipulation under anesthesia C: Exercise interventions O: Patient reported level of disability (SPADI, DASH, OSS, EQ-5D, SDQ etc.)

Question: In patients with adhesive capsulitis, is manipulation under anesthesia more effective than physical therapy/physical therapist guided home exercises in improving patient perceived disability?

To begin our literature review, we utilized both PubMed and CINAHL databases to find articles relevant to our topic. Various search phrases such as adhesive capsulitis, frozen shoulder, manipulation under anesthesia (MUA), and physical therapy were all used when trying to identify important articles. While systematic reviews and randomized control trials would have been ideal articles for this literature review, the lack of research into adhesive capsulitis made this difficult.

Although we were able to identify two systematic reviews and two randomized control trials, the majority of the remaining literature were cohort studies, both prospective and retrospective in nature. Given the wide-ranging quality of articles, we looked to include articles that studied MUA either alone or against another treatment group and used at least one form of patient reported disability as either a primary or secondary outcomes assessment. Of the six articles we decided to include, only two were able to be awarded PEDro scores. Both randomized control trials have associated PEDro scores, one being a 7/10 and the other still being assessed due to the recent publication of that article. We also were able to find a proposed protocol for a randomized control trial looking at MUA versus physiotherapy which may offer hope of higher quality research being available in the future.

Rangan et al. examined MUA and arthroscopic capsular release (ACR) versus physical therapy plus corticosteroid injection in a randomized control trial published in 2020. The article is currently being evaluated to establish a PEDro score.

Subjects of the study included 503 individuals over the age of 18 with unilateral frozen shoulder, identified by restricted passive shoulder external rotation (≥50%).

Subjects were randomly assigned to receive MUA followed by postprocedural physical therapy, ACR followed by postprocedural physical therapy, or early structured physical therapy/home exercise program supplemented with corticosteroid injections, (with a 2:2:1 ratio, respectively). All three groups were assessed via the Oxford Shoulder Score (OSS) and compared to established criteria for target score change/MCID. Secondary measures, including QuickDASH, EuroQOL 5-Dimension Questionnaire (EQ-5D), NPRS, and a perceived extent of recovery VAS were taken. All outcome measures were taken throughout the study, including baseline, 3 months, 6 months, and 12 months following randomization.

Physical therapy interventions were established and standardized based on a literature review and use of a Delphi consensus methodology. Methods and timelines for both MUA and ACR interventions, as well as postprocedural physical therapy interventions, were established.

Findings of the study did not clearly support one intervention over another. At a 12-month follow-up, the surgical interventions did not have better outcomes as compared to physical therapy. ACR had the highest OSS score (40.3) compared to MUA (38.3) and physical therapy (37.2) at 12 months; (OSS ranges from 0-48, with a lower score indicating greater disability).

Despite the OSS data failing to indicate an intervention with a vastly superior outcome, several implications were still drawn from the study. There were potential risks associated with both MUA and ACR interventions that physical therapy interventions alone did not pose. From an economic standpoint, MUA was the most cost-effective. Physical therapy was accessible quickest to study subjects. ACR was costliest and most invasive, but fewer ACR subjects required further treatment following.

A 2019 study by Kraal et al. examined 65 subjects with “stage two frozen shoulder” in a retrospective cohort study. Defined criteria for inclusion was established, including diminished pain compared to stage one, restricted shoulder ROM, and pain at end ranges. The study collected outcome data via the SPADI, OSS, EuroQOL 5-D, pain ratings, and satisfaction ratings. The study also collected subjects’ answers to anchor questions in regards to pre- and post-treatment pain and level of daily functioning. Of the 65 study subjects, 49 completed the outcome measures.

There are several design aspects of the study that must be considered. First, the study has a small sample size and lacks a control group for comparison. Second, both the subjects and the surgeon administering the MUA were not blinded to the treatment, which allows for potential sources of bias. Third, prior to receiving MUA, some study subjects underwent a course of physical therapy treatment with corticosteroid injection, while others did not. However, a 2-week or greater course of post-MUA physical therapy was implemented.

In regards to the collected outcome measures, the data seem to indicate that the subjects were satisfied with the results. Median SPADI scores were reported as 11.2 (IQR 0.8-25.2) and median OSS was 39.0 (IQR 30-43). However, the outcomes were only collected retrospectively without baseline comparator data.

Furthermore, outcome measures were not collected at a standardized time interval following MUA; outcomes were collected at a mean of 21 months following, (range 11-36 months).

The authors contend that MUA can be a potential treatment for frozen shoulder if conservative care fails, in an effort to decrease duration of pain and disability.

Considering the deficiencies of the study design, clinicians should be critical when using these data to drive discussions and decisions.

Another study by Kraal et al. (2017) offered a prospective study structure for a single-center randomized control trial to examine MUA versus physical therapy on treatment for frozen shoulders. The study is designed to randomly allocate subjects with stage two frozen shoulder into either a MUA group or a physical therapy group. Standardization of criteria for subject inclusion was established. Furthermore, outcome measures (including SPADI as the primary measure, OSS, NPRS, EQ-5D, PROM, and WORQ-UP as secondary measures) would be collected at baseline, one month, three months, and one year.

The prospective Kraal et al. study offers a standardized approach that addresses some of the shortcomings of the retrospective study, and will potentially offer data on the matter of MUA versus physical therapy to treat frozen shoulders. This will perhaps establish evidence that can be translated into clinical use.

A 2015 systematic review by Uppal et al. looked to examine the literature on treatment options for frozen shoulder. Due to the longstanding burden that frozen shoulder has posed, without a clear treatment method backed by evidence, this review looks at various options such as physical therapy, use of steroids, hydrodilation, MUA, and ACR. In regards to inclusion criteria, the review included primary frozen shoulders, while excluding articles that included secondary frozen shoulders. However, the review did not establish specific criteria for frozen shoulder (capsular pattern, pain at end-range, etc.), nor phase of the condition. This allows for potential selection bias, which could make the review more prone to inaccurate conclusions.

The review indicates that MUA “...has been shown to be an efficacious treatment. However, the results of manipulation when compared to hydrodilation and steroid injection are equivocal at best.” Though the review made the comparison, it failed to publish objective findings. The review cited one cohort study by Dodenhoff et al.

The 2000 study by Dodenhoff et al. looked to prospectively investigate the effectiveness of MUA on function as assessed by the Constant-Murley score. This study followed 37 subjects and 39 shoulders as they underwent MUA from June 1997 to June 1998. The research team obtained Constant-Murley scores preoperatively and then postoperatively at the three-to-six-week mark, three-month mark, and greater than six-month mark. Patient satisfaction scores were also obtained on this same timeline. The study also looked at range of motion measurements preoperatively and at the postoperative three-to-six-week mark.

Constant-Murely scores range from 0-100 with higher scores being associated with higher levels of function. Median scores were used for comparison at each

check in point for comparison purposes. Scores were found to improve from 24 preoperatively, to 63 at three-to-six-weeks postoperative, to 69 at three-months postoperative and finally to 73 at greater than six-months postoperative. Of all of these changes, only the change in scores from preoperative to three-to-six-weeks postoperative was noted as statistically significant with a p value of <.01.

Significant improvements in range of motion were also found when comparing preoperative to postoperative measurements. Abduction and external rotation measurements were found to improve from 60 degrees and 20 degrees to 120 degrees and 50 degrees respectively. The last outcome measure, patient satisfaction, was found to be as high as 89% at the greater than 6-month postoperative mark.

While findings in this study offer statistically significant positive changes in function, range of motion and satisfaction, these findings should still be taken at face value given the small sample size of the patient population as well as the lack of comparison to other interventions for the treatment of adhesive capsulitis.

However, these findings do offer reason for further research into MUA as a valid treatment for adhesive capsulitis.

The final relevant article found in relation to MUA was a randomized control trial from 2007 by Kivimaki et al. This article researched the effect of MUA with a physical therapist prescribed home exercise program versus the home exercise program alone in the treatment of adhesive capsulitis. The study included 125 subjects who were blindly and randomly assigned to two different treatment groups, one with MUA and home exercise and one with home exercise only. Both treatment groups were instructed in the home exercise program to ensure standardization and underwent baseline assessments and then additional assessments at the six-week, three-month, six-month, and 12-month mark to measure their progress. Outcomes assessment for this study were working ability, pain intensity, the shoulder disability questionnaire (SDQ) and range of motion measurements for shoulder flexion, abduction, inner rotation and outer rotation.

At the conclusion of the study and the 12-month follow-up period, no statistically significant differences were found between the two treatment groups. There were slightly more improved range of motion measurements noted for the MUA group compared to the home exercise only group, but as mentioned before, these differences did not approach statistical significance. Both treatment groups were able to return to functional mobility of the shoulder and exhibited much improved pain and disability scores when compared to baseline.

It should be noted that this study did see relatively high dropout rates over the length of the study, with approximately one third of participants being lost to follow up by the 12 month assessment mark. Of the one third of subjects that were lost to follow up, 28 belonged to the MUA group and 18 belonged to the home exercise only group. This high dropout rate, especially with the majority belonging to the MUA group, may have impacted final results of this study and underreported the true benefits of MUA for the treatment of adhesive capsulitis. This may prompt further research into these two treatment groups with a stricter follow-up protocol and better subject retention to try to achieve more accurate results regarding each intervention.

To conclude, we sought to compare evidence and outcomes on MUA as opposed to physical therapy for treatment of frozen shoulder. In the current body of literature, there is both conflicting evidence and inconclusive evidence on the matter, as demonstrated objectively via the OSS, SPADI, DASH, etc. There is a need for more high-quality evidence in regards to utilizing MUA versus physical therapy intervention in the treatment of frozen shoulder to provide an evidence basis on superiority of treatment.

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