Received: November 7, 2022. Revised: January 2, 2023. Accepted: April 10, 2023
? The Author(s) 2023. Published by Oxford University Press on behalf of the American Physical Therapy Association.
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PTJ: Physical Therapy & Rehabilitation Journal | PhysicalTherapy, 2023;103:1–18
https://doi.org/10.1093/ptj/pzad041
Advance access publication date April 28, 2023
Clinical Practice Guidelines
Physical Therapist Management of Glenohumeral Joint
Osteoarthritis: A Clinical Practice Guideline from the
American Physical Therapy Association
Lori A Michener, PT, ATC, PhD, FAPTA
1
,?
, Jill Heitzman, PT, DPT, PhD
2
,?
,
Laurel D Abbruzzese, PT, EdD
3
, Salvador L Bondoc, OTD, OTR/L, FAOTA
4
, Kristin Bowne, PT, DPT
5
,
Phillip Troy Henning, DO
6
, Heidi Kosakowski, PT, DPT, PhD
7
, Brian G Leggin, PT, DPT
8
,
Ann M Lucado, PT, PhD
9
, Amee L Seitz, PT, DPT, PhD
10
1
Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California, USA
2
Physical Therapy Program, Maryville University, St Louis, Missouri, USA
3
Programs in Physical Therapy, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, Columbia University,
New York City, New York, USA
4
School of Health Sciences, Chatham University, Pittsburgh, Pennsylvania, USA
5
Kristin Bowne Physical Therapy Inc, Napa, California, USA
6
Swedish Spine, Sports & Musculoskeletal Medicine - Issaquah, Seattle, Washington, USA
7
World Physiotherapy, London, UK
8
Good Shepherd Penn Partners, Penn Therapy and Fitness, Philadelphia, Pennsylvania, USA
9
Department of Physical Therapy, College of Health Professions, Mercer University, Macon, Georgia, USA
10
Department of Physical Therapy & Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois,
USA
Address all correspondence to Dr Michener at: practice@apta.org
?
Lori A. Michener and Jill Heitzman contributed equally to this work as co–first authors.
Abstract
A clinical practice guideline on glenohumeral joint osteoarthritis was developed by an American Physical Therapy Association
volunteer guideline development group that consisted of physical therapists, an occupational therapist, and a physician. The
guideline was based on systematic reviews of current scientific and clinical information and accepted approaches for physical
therapist management of glenohumeral joint osteoarthritis.
This clinical practice guideline is available in Spanish; see Supplementary Appendix 8.
Keywords: Physical Therapy, Management, Postoperative, Recommendations, Literature, Guidelines
2 Physical Therapist Management of Glenohumeral Joint Osteoarthritis
Introduction
Overview
This clinical practice guideline (CPG) is based on a systematic
review of published studies involving the physical therapist
management of patients with glenohumeral joint osteoarthri-
tis (GHOA) and those undergoing total shoulder arthroplasty
(TSA).Inadditiontoprovidingpracticerecommendations(see
Table 1 for a summary of recommendations and Table 2 for a
summary of best practice statement recommendations), this
guideline also highlights limitations in the literature, areas
for future research, intentional vagueness, potential benefits,
risks, harms, and costs to implementing each recommenda-
tion, and quality improvement activities.
This CPG is intended to be used by all qualified and
appropriately trained physical therapists and physical ther-
apist assistants involved in the management of individuals
with GHOA and those undergoing TSA. It also is intended to
be an information resource for decision makers, health care
providers, and consumers.
Goals and Rationale
The purpose of this CPG is to help improve the physical
therapist management of individuals with GHOA and those
undergoing TSA. This CPG is based on the current best
evidenceandotherelements ofevidence-based practice,which
is considered to be the integration of best available evi-
dence,clinical expertise,and patient values and circumstances
related to patient and client management, practice manage-
ment,and health policy decision making.
1
To assist clinicians,
this CPG contains a systematic review of the available liter-
ature regarding the management of individuals with GHOA
and those undergoing TSA. This review included randomized
controlled trials and diagnostic studies and identifies where
there is evidence, where evidence is lacking, and topics that
future research must target to improve the physical therapist
managementofindividualswithGHOAandthoseundergoing
TSA.Physical therapist postoperative management for reverse
TSA has been described elsewhere.
2–5
Physical therapist services are provided in diverse settings
by many different providers. This CPG is an educational
tool to guide qualified clinicians through a series of manage-
ment decisions in an effort to improve quality and efficiency
and reduce unwarranted variation of care. Recommendations
guide evidence-based practice while considering the patient’s
wants and needs in the clinical decision-making process. This
CPG should not be construed as including all proper methods
of care or excluding methods of care reasonably directed at
obtaining the same results. The ultimate judgment regarding
the application of any specific procedure or treatment must
be made by the physical therapist in light of all circumstances
presented by the patient, including safety, preferences, and
disease stage, as well as the needs and resources particular to
the locality or institution.
Intended Users
This CPG is intended to be used by physical therapists,
and by physical therapist assistants under the direction of
physical therapists, for the management of patients who have
GHOA, pre- and post-TSA, as well as those currently not
planning to undergo a TSA. Physical therapists are health
care professionals who help individuals maintain, restore,
and improve movement, activity, and functioning to enable
optimal performance and enhance health, well-being, and
quality of life. Orthopedic surgeons, primary care clinicians,
geriatricians, hospital-based adult medicine specialists, physi-
atrists, occupational therapists, nurse practitioners, physician
assistants, emergency department clinicians, and other health
care providers who routinely manage patients with GHOA,
either operatively or nonoperatively, may benefit from this
CPG. It should be used to guide the informed and shared
decision making with the patient for management of GHOA.
Table 1. Summary of Recommendations
a
Intervention Quality of
Evidence
Strength of Recommendation Recommendation
Diagnosis: history, physical exam,
radiograph
Moderate diamondsoliddiamondsoliddiamondsolid? History, physical examination, and radiographs
can be useful to differentially diagnose GHOA.
Critical shoulder angle on radiographs and age are
specifically predictive of the diagnosis.
Diagnosis: MRI High diamondsoliddiamondsoliddiamondsoliddiamondsolid Advanced imaging using MRI is beneficial in the
differential diagnosis of GHOA. MRI is helpful to
confirm the diagnosis but is less useful to rule out
the diagnosis.
Postoperative management: sling
and exercise
High diamondsoliddiamondsoliddiamondsoliddiamondsolid Physical therapists should implement the use of a
sling and progressive exercises for ROM and
strengthening to improve patient-reported
outcomes, and ROM in patients with GHOA who
have undergone total shoulder arthroplasty (TSA).
Postoperative physical therapist–
directed pain management
Moderate diamondsoliddiamondsoliddiamondsolid? Physical therapists should implement the use of a
sling with the shoulder in a neutral rotation
position for pain management in patients with
GHOA who have undergone TSA.
Postoperative physical therapy
timing
Moderate diamondsoliddiamondsoliddiamondsolid? The timing of the introduction of shoulder ROM
exercises by physical therapists may be delayed up
to 4 weeks without negatively impacting
patient-reported outcomes in patients with GHOA
who have undergone TSA.
a
GHOA=glenohumeral joint osteoarthritis; ROM=range of motion; TSA=total shoulder arthroplasty.
Michener et al. 3
Table 2. Summary of Best Practice Statement Recommendations
a,b
Intervention Quality of Evidence Strength of Recommendation Best Practice Statement Recommendation
Preoperative physical therapy for
patients scheduled for TSA
Insufficient diamondsolid??? In the absence of high- or moderate-quality
evidence, the opinion of the GDG based on clinical
expertise is that physical therapist services
delivered preoperatively may benefit postoperative
outcomes in patients with GHOA who are
undergoing TSA.
Nonoperative physical therapy
comparison to other management
strategies
Insufficient diamondsolid??? In the absence of high- or moderate-quality
evidence, the opinion of the GDG based on clinical
expertise is that physical therapist services may
benefit patients with GHOA who have not
undergone TSA.
Nonoperative physical therapist
intervention options
Insufficient diamondsolid??? In the absence of high- or moderate-quality
evidence, the opinion of the GDG based on clinical
expertise is that no one specific intervention
performed by a physical therapist is superior to
another for patients with GHOA.
Postoperative physical therapy
outcomes
Insufficient diamondsolid??? In the absence of high- or moderate-quality
evidence, the opinion of the GDG based on clinical
expertise is that physical therapist services
delivered postoperatively may benefit patient-rated
functional outcomes in the management of
patients who have undergone TSA for GHOA.
Postoperative physical therapy
edema management
Insufficient diamondsolid??? In the absence of high- or moderate-quality
evidence, the opinion of the GDG based on clinical
expertise is that physical therapist interventions for
edema in patients with GHOA who have
undergone TSA should be based on best available
evidence, clinical expertise, and patient values.
a
GDG=guideline development group; GHOA=glenohumeral joint osteoarthritis; TSA=total shoulder arthroplasty. bBest practice statement recommenda-
tions were crafted by the GDG based on discussion of theory, experience treating patients, and other evidence sources as noted in the rationale for each
statement.
This guideline is not intended for use as an insurance benefit
determination document.
Patient Population
Thisguidelineaddressesnonoperative,preoperative,andpost-
operative management of individuals with GHOA, who may
or may not undergo TSA. This document is not intended
to address management of TSA revision, partial or reverse
shoulder arthroplasty, pediatric patients (under 18 years of
age), or patients with primary rheumatoid arthritis.
Burden of Disease
Osteoarthritis (OA) is one of the leading causes of pain,
disability, and health care resource use in the United States,
with over 54 million (23%) older adults diagnosed with OA
and 24 million limited in performing daily activities.
6
One in
4 people with OA report severe pain that limits their ability
to do daily tasks at work and at home, costing over $300
billion in health care costs and lost wages annually.
6
With the
aging population, the incidence of OA is increasing, resulting
in higher costs to the health care system and to the individual
in both dollars and impact on quality of life. As the aging
population increases, this societal impact also will continue
to increase.
The incidence of GHOA is related to the high level of joint
mobility and required use of the GH joint in daily tasks. In
published large-scale population studies, GHOA-associated
degenerative changes have been seen radiographically in 17%
to 20% of adults over the age of 65 years.
7,8
Degenerative
changes in the GH joint are found in up to 17% of patients
with shoulder pain.
9
This condition occurs more frequently in
women than in men and more frequently in those who have
had previous shoulder injuries, have occupations that require
heavy lifting, and are active in sports requiring overhead use
of the upper extremity.
7,10
GHOA can impact quality of life and arm function, espe-
cially related to overhead activities and those requiring shoul-
derexternalrotation.
10
Sleepissueshavebeenreportedrelated
to difficulty falling asleep and to night pain that causes
waking.
10
Psychological factors, such as anxiety and depres-
sion, have been shown to influence pain perception and
impact outcomes of care.
11,12
Treatment for GHOA has
included pain and anti-inflammatory medications (including
injections), thermotherapy, strengthening and flexibility exer-
cises, massage, and bracing. When these interventions are not
effective, surgery of the joint may be indicated in the form of
arthroscopy or TSA.
13
Although joint replacement surgery is
most common in hips and knees, shoulder joint replacements
are the third most commonly performed surgery to mitigate
pain and disability.
14
Annually, 53,000 adults undergo GH
joint replacement surgery, which accounts for 4% of all joint
replacementsandtendstoincreaseinprevalencewithaging.
15
Preoperative health status related to physical strength and
function has been associated with favorable postoperative
outcomes of total joint replacements.
16
These studies related
to total hip arthroplasty and total knee arthroplasty suggest
thatpreoperativeandpostoperativecareforpatientswithTSA
will provide benefits in reducing pain and disability; however,
research in this area for TSA is not available. For patients
being managed postoperatively, a recent study
17
reported a
high prevalence of outpatient falls following shoulder arthro-
plasty. In 198 patients who received shoulder arthroplasty,
4 Physical Therapist Management of Glenohumeral Joint Osteoarthritis
10.6% had a fall after they went home that resulted in visits
to the emergency department and hospital readmission due
to injury to an anatomic site other than the shoulder and/or
injury at the surgical site (eg,periprosthetic humeral fracture).
This begs the question to be answered: What type(s) of
postoperative management is needed to optimize the quality
of life for people who have undergone a TSA?
Etiology
The etiology of GHOA is similar to that of OA in other large
joints via classification into primary or degenerative for no
known cause, or secondary OA related to prior injury or dis-
ease process. GHOA has been characterized by humeral head
cartilage loss with subsequent adaptive changes to the sub-
chondral bone and development of osteophytes that impact
the biomechanical function of the shoulder.
18
In aging, the
collagen content is unchanged but becomes less hydrated and
more permeable. In contrast, with OA, there is an increase
in activity of collagenase and matrix metalloproteinases that
is associated with increased water content, disorganization of
the collagen framework, and breakdown of protein proteo-
glycan content.
19
Multiple factors have been identified that
increase risk of developing GHOA, defined in the risk factor
section.
As GHOA progresses in severity of symptoms and limita-
tions to arm function, a TSA may become an option. The
goal of TSA is to relieve pain and improve function. This
surgery can be indicated when arthritis has progressed to
degeneration of the joint cartilage, impacting the articular
surfaces between the humeral head and the glenoid fossa on
the scapula. Rotator cuff tendon tears, severe fracture, and
rheumatoid disease can also lead to TSA. The humeral head
is held in the glenoid fossa of the scapula by the rotator cuff
muscles and ligaments. During a TSA, prosthetic components
replacethearticularsurfacesofthehumerusandglenoidfossa.
The humeral head and stem are fabricated primarily from
metal, and the stem is fixed into the humeral shaft. Stemless
humeral head implants are also used. The artificial glenoid
socket can be made of polyethylene, metal, or a combination
of both and is fixed into the glenoid socket. Both components
can be press-fitted (pressed into the bone without cement)
or cemented in place. The use of the prosthetic socket is
dependent on the severity of the arthritis and whether the
rotator cuff tendons are still intact.
20
Risk Factors
There are multiple proposed risk factors for GHOA,including
age, genetics, obesity, joint loading, occupation, exercise, GH
joint stability and integrity, rotator cuff arthropathy, and
scapular morphology.
21
Age is a known risk factor, similar
to arthritis in other joints. Prevalence of GHOA has been
reported in 17.4% to 20.3% of those 65 years of age and
older in South Korean and Japanese cohorts.
7,8
Women have
a higher prevalence of GHOA, but being female is not an
independent risk factor.
7,10
Factors other than age that may
lead to secondary OA–such as trauma, shoulder instability,
joint infections, and fracture of the GH joint—are associated
with the development of GHOA. Other anatomical factors
associated with GHOA include rotator cuff tears (and, in par-
ticular, cuff arthropathy) and scapular morphological deficits
that can increase the compressive forces at the GH joint.
Environmental risk factors such as heavy construction jobs
that involve loading to the shoulder and overhead sports
may also play a role in the development of GHOA. Genetics
have been identified as a factor in degenerative joint disease.
Interplaying with genetics are associated risk factors of joint
and systemic inflammation and obesity. Obesity has been
associated more with lower extremity OA but has not been
found to be an independent risk factor for GHOA.
7
Obesity
can be associated with upper extremity OA but is more
intertwined with inflammation and dyslipidemia.
Potential Benefits, Risks, Harms, and Costs
The potential benefits, risks, harms, and costs are provided
for each recommendation within this document. TSA is a
relatively new orthopedic surgery; thus, follow-up studies
are just now emerging from the past 15 years or so, and
overall global harm data are not available. Short- and long-
term follow-up have shown that the radiographic findings of
complications include periprosthetic lucency (thinning of the
bone around the implant), subluxation (partial dislocation of
the implant), and erosion (wearing away) of the bone under-
neath the implant.
22,23
Some of these complications required
revisions due to loosening of the implant, polyethylene wear,
and bone fracture of the humerus (upper arm bone). Most
patient complaints focused on loss of motion, persistent pain,
and need for revision.
Emotional and Physical Impact
Psychological factors can impact pain and functional out-
comes.
21
Patients undergoing hip or knee joint arthroplasty
who had high Medical Outcomes Study 36-Item Short-Form
Survey (SF-36) mental health scores had lower functional
outcomes both preoperatively and postoperatively than did
those with lower psychological distress.
24
In patients with
GHOA undergoing TSA, those with higher depression and
anxiety scores preoperatively had fewer improvements post-
operatively in self-report function and pain.
11
Assessment of
psychological factors may be indicated to determine if the
management of the mental health factors is indicated.
25
A
comprehensive screening tool may be helpful to identify the
presence of psychosocial factors that can impact recovery,
such as the Optimal Screening for Prediction of Referral and
Outcome for Yellow Flags (OSPRO-YF).
26
The presence of GHOA and undergoing TSA can impact
functionallimitationsoftheshouldercomplexthatcanreduce
the ability to perform social and work-related tasks involving
the upper extremity. Depending on the tasks (both at home
and in the workplace), the demands on the muscular and
joint structures of the shoulder complex may lead to awkward
posturestoperformataskresultinginfatigueandoverusesyn-
dromes. Additionally, psychosocial work issues may alter an
individual’s perception of pain and functional difficulties and
thus impact recovery.
10
Patient-reported functional outcomes
indicate that surgical (TSA) and nonsurgical management that
includes physical therapist services can be beneficial.
27–29
Future Research
Consideration for future research is provided for each recom-
mendation within this document.
Methods
The methods used to develop this CPG were employed to
minimize bias and enhance transparency in the selection,
Michener et al. 5
appraisal, and analysis of the available evidence. These pro-
cessesarevitaltothedevelopmentofreliable,transparent,and
accurateclinicalrecommendationsforphysicaltherapistman-
agement of GHOA and TSA.Methods from the APTA[Amer-
icanPhysicalTherapyAssociation]ClinicalPracticeGuideline
Manual
30
and AAOS [American Academy of Orthopaedic
Surgeons] Clinical Practice Guideline Methodology
31
were
used in development of this CPG.
This CPG evaluates the effectiveness of approaches in the
physical therapist management of GHOA. APTA sought out
the expertise of the AAOS Evidence-Based Medicine Unit as
paid consultants to assist in the methodology of this CPG.
The multidisciplinary guideline development group (GDG)
consisted of physical therapist members from APTA and its
representative sections and academies, AAOS, the Ameri-
can Occupational Therapy Association, and the American
Academy of Physical Medicine and Rehabilitation (Fig. 1).All
GDG members, APTA staff, and methodologists were free of
potential conflicts of interest relevant to the topic under study,
as recommended by the National Academies of Sciences and
Medicine’s Clinical Guidelines We Can Trust.
15
This CPG was prepared by the APTA Glenohumeral
Joint Osteoarthritis Clinical Practice Guideline Development
Group (clinical experts) with the assistance of the AAOS Clin-
ical Quality and Value (CQV) Department (methodologists).
To develop this guideline, the GDG held an introductory
meeting on June 16, 2020, to establish the scope of the
CPG. The GDG defined the scope of the CPG by creating
PICOT questions (ie, population, intervention, comparison,
outcome, and time) that directed the literature search. The
AAOS medical librarian created and executed the search.
(Suppl. Appendix 1 contains the search strategy.) AAOS
chose the included studies and performed quality assessments
based on the published guideline methodology. The GDG
performed final reviews of the literature and recommenda-
tions, provided rationale in the context of physical therapist
practice, and adjusted the strength of the recommenda-
tions depending on the magnitude of benefit, risk, harm,
and cost.
Quality appraisals, diagnosis evidence tables, and interven-
tion evidence tables are found in Supplementary Appendixes
2, 3,and4, respectively.
Best Evidence Synthesis
This CPG includes only the best available evidence for any
given outcome addressing a recommendation. Accordingly,
the highest-quality evidence for any given outcome is included
first if it was available. In the absence of 2 or more occur-
rences of an outcome based on the highest-quality (Level I)
evidence, outcomes based on the next level of quality were
considered until at least 2 or more occurrences of an outcome
had been acquired (Tab. 3). For example, if there were 2
“moderate” quality (Level II) occurrences of an outcome
that addressed a recommendation, the recommendation does
not include “low” quality (Level III) occurrences of evidence
for this outcome. For best practice statement recommenda-
tions for which high- or moderate-quality studies were not
available, the other 2 elements of evidence-based practice
(clinician experience and knowledge base, and patient values
and preferences) were used to make the recommendation.
A summary of included and excluded articles is included in
Supplementary Appendixes 5 and 6. A flowchart of study
attrition is found in Figure 2.
Literature Searches
The medical librarian conducted a comprehensive search
of PubMed, Embase, and the Cochrane Central Register of
Controlled Trials based on key terms and concepts from
the PICOT questions. Bibliographies of relevant systematic
reviews were hand searched for additional references. All
databases were last searched on December 8, 2020, with
limits for publication dates from 1990 through 2020 and
English language. The PICOT questions used to define the
literature search and inclusion criteria, and the literature
search strategy used to develop this CPG, can be found in
Supplementary Appendix 1.
Defining the Strength of the Recommendations
Judging the quality of evidence is only a steppingstone toward
arriving at the strength of a CPG recommendation. The
operational definitions for the quality of evidence are listed
in Table 3, and rating of magnitude of benefits versus risk,
harms, and cost is provided in Table 4. The strength of rec-
ommendation (Tab. 5) also takes into account the quality,
quantity, and trade-off between the benefits and harms of a
treatment, the magnitude of a treatment effect, and whether
there are data on critical outcomes. Table 6 addresses how to
linktheassignedgradewiththelanguageofobligationofeach
recommendation.
Patient Involvement
FourindividualswhohadGHOAand/oraTSAparticipatedin
the development of this CPG through the peer-review process.
These reviewers provided input on the final draft, which the
GDG took into consideration in making any necessary edits
to the CPG (Suppl. Appendix 7).
Voting on the Recommendations
GDG members agreed on the strength of every recommen-
dation; recommendations were approved and adopted when
a majority of 60% of the GDG voted to approve. All rec-
ommendations received 100% agreement among the quorum
of the voting GDG. No disagreements were recorded during
recommendation voting. When changes were made to the
strength of a recommendation based on the magnitude of
benefit or potential risk, harm, or cost, the GDG voted and
provided an explanation in the rationale.
Structure of the Recommendations
Each recommendation contains information on the quality
of the body of evidence and the strength of each recommen-
dation. Additional categories are also provided for potential
benefits, risks, harms, and costs of implementing each rec-
ommendation; future research; value judgments; intentional
vagueness; exclusions; quality improvement; and implemen-
tation and audit. The rationales for each recommendation
are intended to provide the reader with an overview of the
included studies, highlighting consistencies or discrepancies
in results where applicable, and are not intended to provide
specific details of each study. References of the included
studies for each recommendation are provided in the action
statement profiles, and readers are encouraged to search indi-
vidual studies for details.Additionally,information on quality
improvement (what aspect of practice will improve as a result
of following the recommendation) and implementation and
6 Physical Therapist Management of Glenohumeral Joint Osteoarthritis
Figure 1. Guideline Development Group roster.
Table 3. Rating Quality of Evidence
Rating Of Overall Quality
Of Evidence
Definition
High Preponderance of Level I or II evidence with at least 1 Level I study. Indicates a high level of certainty
that further research is not likely to change outcomes of the combined evidence.
Moderate Preponderance of Level II evidence. Indicates a moderate level of certainty that further research is not
likely to change the outcomes direction of the combined evidence; however, further evidence may
impact the magnitude of the outcome.
Low A moderate level of certainty of slight benefit, harm, or cost, or a low level of certainty for
moderate-to-substantial benefit, harm, or cost. Based on Level II through V evidence. Indicates that
there is some but not enough evidence to be confident of the true outcomes of the study and that future
research may change the direction of the outcome and/or impact magnitude of the outcome.
Insufficient Based on Level II through V evidence. Indicates that there is minimal or conflicting evidence to support
the true direction and/or magnitude of the outcome. Future research may inform the recommendation.
Michener et al. 7
Figure 2. Study attrition flowchart.
Table 4. Magnitude of Benefit, Risk, Harms, or Cost
Rating of Magnitude Definition
Substantial The balance of the benefits versus risk, harms, or cost overwhelmingly supports a specified direction.
Moderate The balance of the benefits versus risk, harms, or cost supports a specified direction.
Slight The balance of the benefits versus risk, harms, or cost demonstrates a small support of a specified direction.
audit (specific strategies for implementing a particular recom-
mendation and how its implementation might be measured
for adherence) is provided for each recommendation.
Outcome Measures
Assessment of ROM (passive and active), strength, pain,
anthropometrics, and mechanics of the shoulder complex
along with patient-reported outcome measures should be
used to develop a patient-specific treatment plan and
determine patient response to care. Valid and reliable
patient-reported outcome measures are an important part
of the initial assessments and reassessments to quantify
the patient perspective of symptoms, activity limitations,
and participation restrictions. A triangulation of patient-
reported outcome measures may be useful when assess-
ing the impact on activity limitations and participation
restrictions. A condition-specific, upper extremity-specific, or
shoulder-specific outcome measure may be included as 1 piece
of outcome assessment. The Western Ontario Osteoarthritis
Score (WOOS) Shoulder Index is a specifically designed
outcome measure to assess symptoms,function/disability,and
emotions in patients with shoulder osteoarthritis.
32
Examples
of upper extremity measures include the Disability of the
Arm,Shoulder and Hand (DASH) or its shortened version,the
QuickDASH.
33,34
Many shoulder specific outcome measures
would be appropriate to assess patients with GHOA and/or
preoperative and postoperative TSA, such as the Shoulder
Pain and Disability Index (SPADI),
35,36
Penn Shoulder Score
(PENN),
37
Simple Shoulder Test (SST),
38–40
and American
Shoulder and Elbow Surgeons score (ASES).
40,41
The ASES
andWOOShavebeendemonstratedtobethemostresponsive
of extremity-specific and condition-specific measures in
patients undergoing TSA.
42
Patient-specific measures should
also be used to guide individual patient care, such as the
Patient-Specific Functional Scale (PSFS).
43,44
Finally, an
8 Physical Therapist Management of Glenohumeral Joint Osteoarthritis
Table 5. Strength of Recommendations
Strength Strength Visual Definition
Strong diamondsoliddiamondsoliddiamondsoliddiamondsolid A high level of certainty of moderate-to-substantial benefit, harms, or cost or a moderate level
of certainty for substantial benefit, harms, or cost (based on a preponderance of Level I or II
evidence with at least 1 Level I study).
Moderate diamondsoliddiamondsoliddiamondsolid? A high level of certainty of slight-to-moderate benefit, harms, or cost or a moderate level of
certainty for a moderate level of benefit, harms, or cost (based on a preponderance of Level II
evidence or a single high-quality RCT).
Weak diamondsoliddiamondsolid?? A moderate level of certainty of slight benefit, harms, or cost or a low level of certainty for
moderate-to-substantial benefit, harms, or cost (based on Level II through V evidence).
Theoretical/
foundational
diamondsolid??? A preponderance of evidence from animal or cadaver studies, from conceptual/theoretical
models/principles, from basic science/bench research, or from published expert opinion in
peer-reviewed journals that supports the recommendation.
Best practice diamondsolid??? Recommended practice based on current clinical practice norms; exceptional situations in
which validating studies have not or cannot be performed yet there is a clear benefit, harm, or
cost; or expert opinion.
Table 6. Linking the Strength of Recommendation, Quality of Evidence, Rating of Magnitude, and Preponderance of Risk vs Harm to the Language of
Obligation
a
Recommendation
Strength
Quality Of Evidence and Rating of Magnitude
Preponderance of Benefit or Risk,
Harms, or Cost
Level of Obligation to Follow the
Recommendation
Strong High-quality and moderate-to-substantial
magnitude
or
Moderate-quality and substantial magnitude
Benefit Must or should
Risk, harms, or cost Must not or should not
Moderate High-quality and slight-to-moderate magnitude
or
Moderate-quality and moderate magnitude
Benefit Should
Risk, harms, or cost Should not
Weak Moderate-quality and slight magnitude
or
Low quality and moderate-to-substantial
magnitude
Benefit May
Risk, harms, or cost May not
Theoretical/
foundational
N/A Benefit May
Risk, harms, or cost May not
Best practice Insufficient quality and insufficiently clear
magnitude
Benefit Should or may
Risk, harms, or cost Should not or may not
a
N/A=not applicable.
anchor may be helpful to interpret the patient-reported
outcome scores, such as determining the Patient Acceptable
Symptom State
45
or simply asking if the patient is satisfied
with their current status. Patient-reported outcome measures
can be found on the APTA webpage for tests and measures.
46
Role of the Funding Source
APTA, which funded AAOS services and provided coordina-
tion, played no role in the design, conduct, and reporting of
the recommendations.
Peer Review and Public Commentary
Following the formation of a final draft, the CPG draft
was subjected to a 3-week peer review for additional input
from external content experts and stakeholders. Eighty-four
comments from 5 professional societies were collected via
an electronic structured review form. All peer reviewers were
required to disclose any potential conflicts of interest, which
were recorded and, as necessary, addressed.
After modifying the draft in response to peer review, the
CPG was subjected to a 2-week public comment period.Com-
menters consisted of the APTA Board of Directors (Board),
the APTA Scientific and Practice Affairs Advisory Committee
(SPAC), all relevant APTA sections and academies, stake-
holder organizations, and the physical therapy community at
large. Ten public comments were received. Revisions to the
draft were made in response to relevant comments.
Recommendations
Diagnosis: History, Physical Examination, and
Radiograph diamondsoliddiamondsoliddiamondsolid?
History, physical exam, and radiographs can be useful to
differentially diagnose GHOA; specifically, critical shoulder
angle on radiograph and age can be predictive of the diagno-
sis. Evidence Quality: moderate; Recommendation Strength:
moderate.
Action Statement Profile
Aggregate Evidence Quality: 1 high-quality study
47
and 1
moderate-quality study.
48
Rationale
One high-quality study found that age was useful to differ-
entially diagnose GHOA from other similar conditions; older
age was noted in those with cuff arthropathy, and younger
Michener et al. 9
age was noted in those with rotator cuff tears.
48
One high-
quality study
47
and 1 moderate-quality study
48
found that
a decrease in the critical shoulder angle in true anterior–
posterior radiographs was useful to diagnose GHOA. (Crit-
ical shoulder angle is defined as the angle between the line
connecting the superior and inferior osseous margins of the
glenoid cavity [parallel to glenoid surface] and a second line
from the inferolateral border of the acromion to the infe-
rior glenoid margin.
48
) Evidence and consensus-based patient
care pathways developed with the National Health Service
Evidence-BasedInterventionsprogramintheUnitedKingdom
indicate that GHOA diagnosis should include symptoms of
shoulder pain occurring for more than 3 months, no findings
of instability or localized pain to the AC joint upon manual
examination, a global reduction in range of motion (ROM)
with the greatest loss in passive external rotation with the
arm at the side, and radiographs to confirm the diagnosis.
49
Differential diagnosis should be performed for rotator cuff
tendon pathology, adhesive capsulitis, and labral tears that
may have a similar patient presentation.
49
Diagnosis: Magnetic Resonance Imaging (MRI)
diamondsoliddiamondsoliddiamondsoliddiamondsolid
Advanced imaging through MRI is beneficial in the differ-
ential diagnosis of GHOA. MRI is helpful to confirm the
diagnosis but is less useful to rule out the diagnosis. Evidence
Quality: high; Recommendation Strength: strong.
Action Statement Profile
Aggregate Evidence Quality: 2 high-quality studies.
50,51
Rationale
Two high-quality studies found that MRI without contrast is
helpful to confirm the diagnosis of GHOA but less useful to
rule it out.
50,51
An MRI-based grading system for shoulder
osteoarthritis severity is reliable and useful to detect early
OA, classify severity, and track progression of shoulder OA.
Consensus-based patient care pathway
49
indicates that the
first step in diagnosis is the use of a clinical examination and
radiographs to diagnose GHOA. Use of advanced imaging of
MRI may be indicated if the diagnosis is unclear. Physical
therapists can use the American College of Radiology Appro-
priateness Criteria for guidance.
52
Potential Benefits, Risks, Harms, and Costs of
Implementing these Recommendations
Benefits are as follows:
? Aids in clinical decision making and differential diagnosis
Risk, harms, and/or costs are as follows:
? There are no risks or harms with performing the history
and physical examination.
? There are costs associated with performing unnecessary
radiologic imaging; for example, use of advanced imaging
such as MRI does increase the cost of care.
Benefit-harm Assessment.
History/Physical Exam/Radiographs: The balance of the
benefits versus risk, harms, or cost supports this recommen-
dation.
MRI: The balance of the benefits versus risk,harms,or cost
overwhelmingly supports this recommendation.
Future Research
Future studies should continue to evaluate the ability of
the history, physical examination, and imaging to diagnose
GHOA. This would enable increased certainty in the diag-
noses of GHOA and enable specific care pathways for the
nonoperative management of GHOA.
Value Judgments
Physical therapists use clinical decision making and differen-
tial diagnosis skills during the physical examination to deter-
mine the plan of care, which may include the need for other
health care provider involvement. Some states have granted
physical therapists the legal ability to order radiographs,
53
which can be used for diagnosis of GHOA.
Intentional Vagueness
Differential diagnosis from other musculoskeletal conditions
was not included in the search.
Exclusions
Diagnostic ultrasound was not included, as there was no
available literature.
Quality Improvement
Organizations may use documentation of history, physical
examination,and referral for and/or evidence of a radiograph
or MRI as a performance indicator.
Implementation and Audit
Organizationsmayauditoccurrenceofhistory,physicalexam,
and referral for and/or evidence of radiograph or MRI.
Postoperative Management: Sling and
Exercise diamondsoliddiamondsoliddiamondsoliddiamondsolid
Physical therapists should implement the use of a sling and
progressive exercises for ROM and strengthening to improve
patient-reported outcomes,and ROM in patients with GHOA
who have undergone TSA. Evidence Quality: high; Recom-
mendation Strength: strong.
Action Statement Profile
Aggregate Evidence Quality: 2 high-quality studies.
54,55
Rationale
One high-quality study indicates improved patient-reported
outcomes and ROM in patients with primary GHOA who
have undergone TSA (with lesser tuberosity osteotomy) who
were randomized to immediate motion versus delayed motion
during the 4-week immobilization period.
54
Postoperative
physical therapist services in the high-quality study consisted
of sling use for 4 weeks, followed by 4 weeks of progressive
assistive and active ROM and then strengthening exercises.
54
This randomized clinical trial (n=60 patients), showed
earlier improvements (at 4 and 8 weeks) in ROM and
patient-reported functional outcomes (ASES scores) with
immediate ROM exercises (flexion and external rotation to
30
?
) compared with delayed motion (4 weeks) during the
10 Physical Therapist Management of Glenohumeral Joint Osteoarthritis
immobilization period, but no differences in ROM, pain, or
patient-reported function (ASES, SST, SANE), at 1 year.
54
One high-quality study of patients (n=36) who received
standard physical therapy, and randomized to either neutral
or internal rotation sling position for 6 weeks following
TSA. The internal rotation position was with the forearm
positioned againstthestomach.The neutral slingposition was
described by authors using “the Slingshot 3 sling (Arthrex,
Naples, FL, USA) that maintained the glenohumeral joint in
neutral rotation and attempted to maintain a neutral scapular
position.”
55
Results suggest both sling immobilization posi-
tions had significant improvements in pain, patient-reported
function(DASH,WOOS,SANE),andROMoutcomes.
55
Dur-
ing6weeksofimmobilization,patientswhowererandomized
to use of a sling in a neutral shoulder position had less night
pain at 2 weeks postoperative and greater ROM in exter-
nal rotation at 1 year compared with patients immobilized
in a traditional internal rotation sling.
55
Immobilization in
a neutral position should be considered as a management
option.
Potential Benefits, Risks, Harms, and Costs of
Implementing this Recommendation
Benefits are as follows:
? Improved patient-reported arm function
? Decrease in postoperative day and night pain
? Improved ROM
Risks, harms, and/or costs are as follows:
? ThereisnoharminROMandfunctionaloutcomes(ASES)
with delayed ROM (4 weeks) compared with immediate
activeassistiveROMexerciseswithfollow-upat6months
and 1 year. While earlier gains in ROM can occur when
ROM exercises are initiated immediately postoperative,
there is a small risk for adverse healing of subscapularis
with immediate ROM versus the delayed group following
TSA.
54
? Impaired subscapularis or osteotomy healing after TSA
results in higher level of pain, instability, and reduced
active internal rotation ROM.
54,56–58
Protection of sub-
scapularis healing during the early postoperative healing
stage of recovery with delayed ROM (4 weeks) and initi-
ating ROM with limits in external rotation to 30 degrees
should be considered.
Benefit-harmassessment:The balance of the benefits versus
risk, harms, or cost overwhelmingly supports this recommen-
dation.
Future Research
Since ROM exercises are the standard of care for physical
therapist intervention of patients following TSA, randomized
trials with control groups comparing physical therapist inter-
ventions without progressive ROMexercise isunlikely.Future
research should evaluate which physical therapist interven-
tions (passive ROM versus active assistive; formal strength-
ening versus ADLs) and dosing of interventions are the most
effective to improve patient-reported outcomes. Comparative
studiesonthetimingofinitiatingpassiveandactiveROMand
strengthening are also recommended. The impact of implant
designs (eg, stemmed, stemless) and subscapularis fixation
methods (eg, tenotomy, less tuberosity osteotomy, and peel
to bone tunnels) and healing of the subscapularis should be
considered in relationship to ROM guidelines after TSA.
Value Judgments
Sling use and delayed exercises are intended for manage-
ment of the GHOA and may affect other regions in the
upper extremity. Therefore, the function of the entire upper
extremity should be assessed to determine if physical therapist
management is appropriate.
Intentional Vagueness
The position of the shoulder in a sling would include a bolster
with the shoulder in abduction and neutral glenohumeral
rotation. Specific dose and type of exercises are not defined.
Precautions about weight-bearing on the operated extremity
during transfers or functional activities were not specifically
described.
Exclusions
Studies of nonprimary OA (rotator cuff tear arthropathy or
reverse TSA) were excluded.
2,59
Quality Improvement
Organizations may use documentation of sling immobiliza-
tion position and duration, exercise parameters to include
ROM exercises as a performance indicator. Patient-rated out-
comes of care should be assessed to determine effectiveness
and areas for improvement.
Implementation and Audit
Organizations may audit occurrence of early exercise follow-
ing TSA for management of GHOA.
Postoperative Physical Therapist–Directed Pain
Management diamondsoliddiamondsoliddiamondsolid?
Physical therapists should implement the use of a sling with
the shoulder in a neutral rotation position for pain man-
agement in patients with GHOA who have undergone TSA.
Evidence Quality: moderate; Recommendation Strength:
moderate.
Action Statement Profile
Aggregate Evidence Quality: 1 high-quality study.
55
Rationale
One high-quality study assessed the effects of arm position
(shoulder neutral glenohumeral rotation versus internal rota-
tion) during 6-week sling immobilization on patient-reported
outcomes. The neutral position was described by authors as
using “the Slingshot 3 sling (Arthrex, Naples, FL, USA) that
maintained the glenohumeral joint in neutral rotation and
attempted to maintain a neutral scapular position.”
55
The
neutral rotation sling group demonstrated less night pain at
2 weeks but no differences at longer-term follow-up at 6,
12, 32, and 54 weeks. Positioning the arm in a sling in neu-
tral rotation resulted in slightly better patient-reported pain
outcomes (DASH, WOOS, SANE) compared with internal
rotation, but the difference was not statistically significant.
Improved pain ratings (overall and night) were seen in both
groups who were immobilized in a sling for the first 6 weeks
postoperatively in conjunction with a standardized program
Michener et al. 11
supervised by physical therapists. Sling use in neutral arm
position should begin postoperatively, with instructions from
the surgeon if passive range-of-motion (PROM) exercises,
such as pendulum, may be performed out of sling until the
patient initiates physical therapy.
Potential Benefits, Risks, Harms, and Costs of
Implementing this Recommendation
Benefits are as follows:
? Improved patient-reported arm function
? Decrease in postoperative daily and night pain
? Improved ROM
Risks, harms, and/or costs are as follows:
? Loss of ROM/shoulder joint contracture if protected
ROM is not initiated or properly performed.
Benefit-harmassessment:The balance of the benefits versus
risk, harms, or cost supports this recommendation.
Future Research
Studies are needed that characterize the effects of physical
therapy modalities for pain, optimal duration of sling use on
pain and functional outcomes.Importantly,studies areneeded
to define optimal multimodal pain management strategies for
patients with TSA and GHOA. Large sample sizes could help
to determine the optimal position of shoulder rotation during
sling immobilization.
Value Judgments
As pain is an important aspect of quality of life, the need for
pain control was determined to be an important consideration
despite having only 1 quality study.
Intentional Vagueness
The position of the shoulder in a sling would include a bolster
with the shoulder in abduction and neutral glenohumeral
rotation.
Exclusions
No exclusions were identified. Other methods for pain man-
agement exist but were not included in the literature base for
this recommendation.These include the use of cryotherapy or
other physical modalities.
Quality Improvement
Organizations may use documentation of sling immobiliza-
tion position, duration, and pain intensity as performance
indicators. Patient-rated outcomes of care should be assessed
to determine effectiveness and areas for improvement.
Implementation and Audit
Organizations may audit the occurrence of documentation
of sling immobilization for management of pain control in
patients with GHOA and management postoperative of TSA.
Postoperative Physical Therapy Timing diamondsoliddiamondsoliddiamondsolid?
The timing of the introduction of shoulder ROM exercises by
physical therapists may be delayed up to 4 weeks without
negatively impacting patient-reported outcomes in patients
with GHOA who have undergone TSA. Evidence Quality:
moderate; Recommendation Strength: moderate.
Action Statement Profile
Aggregate Evidence Quality: 1 high-quality study.
54
Rationale
One high-quality study
54
of 60 individuals who had under-
goneaTSAusingalessertuberosityosteotomyapproachcom-
pared immediate with delayed (4 weeks) ROM exercises and
found no difference between groups in outcomes. Treatment
consisted of sling use for 4 weeks, followed by 4 weeks of
progressive assistive and active ROM, and then strengthening
exercises. Outcome measures included ROM measurements,
visual analog scale (VAS), ASES, STT, and SANE scores. At
1 year postoperatively, there were no significant differences
between groups in any of the outcomes. During the early
phase of the study, the immediate group showed improved
trends in external rotation and forward flexion ROM, VAS,
SANE,and ASES scores.However,these differences narrowed
over time, with no differences seen by 3 months. Of concern,
nonhealing of the lesser tuberosity osteotomy was higher in
the immediate ROM group (5/27=19%) than in the delayed
group (1/28=4%). Other studies
60,61
have shown trends
toward greater functional improvement with healing of the
osteotomy orsubscapularistenotomy repairwhenROMexer-
cises were delayed. Although this study is related to shoulder
exercises, this does not preclude the need for exercising the
other upper quadrant muscles and joints,such as neck,elbow,
and hand. The need for early PROM should be individualized
to the patient’s needs and type of surgery. Overall, the timing
of initiation of physical therapist services related to ROM
exercises does not affect patient-related outcomes.
? Initial limitation of external rotation to 30 degrees is rec-
ommended to avoid increased stress on the lesser tuberos-
ity osteotomy site.
? Patientpresentation/characteristicsofoverallhealthstatus
can help determine timing.
? Protection of the subscapularis during the healing phase
postoperatively must be a primary objective.
There was no evidence evaluating the intensity levels of
ROM exercises with respect to timing of delivery. Physical
therapists should be guided by the individual patient evalua-
tion and their goals and should consider the need for adequate
healing of the osteotomy in patients when determining the
intensity and timing of treatment.
Potential Benefits, Risks, Harms, and Costs of
Implementing this Recommendation
Benefits are as follows:
? No difference between immediate and delayed ROM exer-
cises on patient-reported functional outcomes
? Relief from pain and swelling with ROM exercises
Risks, harms, and/or costs are as follows:
? Early stress on the subscapularis tenotomy or lesser
tuberosity osteotomy may impair healing rates, which
has been shown to compromise long-term functional
outcomes.
12 Physical Therapist Management of Glenohumeral Joint Osteoarthritis
? EarlyinitiationofROMexerciseshasbeenassociatedwith
delayed lesser tuberosity osteotomy healing.
Benefit-harmassessment:The balance of the benefits versus
risk, harms, or costs supports this recommendation.
Future Research
Studies are needed to determine optimal timing for exercise
for patient management after TSA and to determine factors
of muscle integrity and surgical variables (including various
implants and fixation methods) related to exercise imple-
mentation and healing. Determining the type and/or timing
of exercise implementation can enable the optimization of
postoperative healing, pain relief, and long-term functional
outcomes. Comparative studies on the timing of initiating
passive and active ROM and strengthening are also rec-
ommended. The impact of implant designs (eg, stemmed,
stemless) and subscapularis fixation methods (eg, tenotomy,
less tuberosity osteotomy, and peel-to-bone tunnels) and the
impact of healing of the subscapularis should be considered
in relationship to ROM guidelines after TSA.
Value Judgments
While outcomes at 1 year were similar for the shoulder, this
recommendation does not speak to interventions for other
joints of the upper extremity to maintain function.
Intentional Vagueness
Timing was left vague; intensity of ROM exercise was not
defined.
Exclusions
No exclusions were identified.
Quality Improvement
Organizations may use information provided by the patient,
care team documentation, and referral to help make decisions
related to the timing of physical therapist services. Patient-
rated outcomes of care should be assessed to determine effec-
tiveness and areas for improvement.
Implementation and Audit
Organizations may audit occurrence of history, care team
documentation, and referral for timing the physical therapist
intervention(s).
Best Practice Statements
Best practice statement recommendations were crafted
by the GDG based on discussion of theory, experience
treating patients, patient values and preferences, and other
evidence sources as noted in the rationale for each
statement.
Preoperative Physical Therapy for Patients
Scheduled for TSA diamondsolid???
In the absence of high or moderate-quality evidence, the
opinionoftheGDGbasedonclinicalexpertiseisthatphysical
therapist services delivered preoperatively may benefit post-
operative outcomes in patients with GHOA who are under-
going TSA. Evidence Quality: insufficient; Recommendation
Strength: best practice.
Action Statement Profile
Aggregate Evidence Quality: 0 included studies.
Rationale
There are no studies investigating the effects of preoperative
physical therapist services on patient-reported outcomes for
those undergoing TSA for GHOA. The AAOS guidelines
62
and the United Kingdom’s NICE Guidelines
63
for manage-
ment of GHOA indicate that preoperative physical therapist
services may decrease pain, restore function, and, in some
cases, may eliminate the need for surgery.
Systematic reviews report benefits of preoperative physi-
cal therapist services for lower extremity joint replacements.
A systematic review
64
found preoperative patient education
before total knee arthroplasty improved patient knowledge
and expectations, knee motion, and postoperative exercise
performance. A more recent systematic review and meta-
analysis
65
reported that preoperative education and physical
therapist services improved function and decreased length of
stay for both total hip and knee arthroplasty.They also found
decreased pain for those who had a total hip arthroplasty
and improved quadriceps strength in those undergoing total
knee arthroplasty.
65
A recent randomized trial not included
in the prior systematic reviews
66
found that those undergoing
total knee arthroplasty who received preoperative physical
therapy took less pain medication and had improved physical
activity both preoperatively and postoperatively compared
with a control group that maintained activity as tolerated.
Based on these studies for other joint replacements, preop-
erative physical therapist services may be beneficial for those
undergoing a TSA for GHOA. The preoperative treatment
should include exercise, pain management, and education for
expectations of function and lifestyle after surgery. This may
improve physical activity and decrease pain and may reduce
overall health care costs. Patients with GHOA should be
offered preoperative physical therapy at least 6 weeks prior
to surgery.
Potential Benefits, Risks, Harms, and Costs of
Implementing this Recommendation
Benefits are as follows:
? Improved physical activity
? Decreased pain
? Improved postoperative patient-reported outcomes
? Improved expectations of outcomes following surgery
? Reduced length of stay
Risks, harms, and/or costs are as follows:
? A finite number of physical therapy visits may be available
based on patient health care resources, and thus preoper-
ative visits may reduce the available visits for postopera-
tive care.
? There are no known harms related to physical therapist
services with interventions that are appropriately designed
to match the patient’s irritability level.
67
Increased pain
may result if intervention intensity and selection are not
matched to the patient’s level of irritability.
Future Research
Future research should focus on comparing the effects of
preoperative physical therapist services with no preoperative
Michener et al. 13
management on postoperative outcomes of pain, function,
and length of stay in patients undergoing TSA for GHOA.
Additionally, research should determine the optimal dose and
components of preoperative management that may lead to the
best postoperative outcomes.
Value Judgments
With no studies directly assessing the effects of preoperative
physical therapy,the APTA CPG for total knee arthroplasty
68
indicates the benefit of preoperative physical therapy and
education, which could be applied to TSA as well.
Intentional Vagueness
No specifics for preoperative TSA were found.
Exclusions
No exclusions were identified.
Quality Improvement
Organizations may use information provided by the patient,
care team documentation, imaging, and physical examination
to help develop preoperative goals for physical therapist ser-
vices. Patient-rated outcomes of care should be assessed to
determine effectiveness and areas for improvement.
Implementation and Audit
Organizationsmayauditoccurrenceofhistory,careteamdoc-
umentation, and prior imaging to help develop goals related
to preoperative physical therapist intervention(s).
Nonoperative Physical Therapy Comparison to
Other Management Strategies diamondsolid???
In the absence of high or moderate quality evidence, the
opinionoftheGDGbasedonclinicalexpertiseisthatphysical
therapist services may benefit patients with GHOA who have
not undergone TSA. Evidence Quality: insufficient; Recom-
mendation Strength: best practice.
Action Statement Profile
Aggregate Evidence Quality: 0 included studies.
Rationale
Nohigh-ormoderate-qualitystudiesexistexaminingphysical
therapist services of multimodal treatment compared with
placebo, wait and see/no treatment, or surgical management
for patients with GHOA who are not seeking TSA. Surgical
interventions for patients diagnosed with GHOA should be
reserved for patients who fail nonoperative management to
address pain, limitation in motion, and loss of function.
49,63
Nonoperative management for GHOA can include nons-
teroidal anti-inflammatory drugs (NSAIDs), acupuncture,
local injections, and rehabilitation management to include
physical therapy. In a prospective cohort (n=129) of older
adults (65 years or older) with GHOA,
29
patients were
treated nonoperatively with a combination of NSAIDs,
corticosteroid and sodium hyaluronate injections, education,
and physical therapist management including ROM and
muscular strengthening exercises. Although this represents
low-level evidence, the study participants demonstrated
improvements in perceived function, pain, mental health, and
health-related quality of life at 3 years’ follow-up.
29
Potential Benefits, Risks, Harms, and Costs of
Implementing this Recommendation
Benefits are as follows:
Some patients with primary GHOA receiving physical ther-
apist management have:
? Improved ROM
? Improved pain management
? Improved function
There is potential benefit of physical therapist intervention
for some patients who are unable to undergo TSA or for
patients who respond favorably to a trial of conservative
treatment that includes physical therapy.
Risks, harms, and/or costs are as follows:
? There are no known harms related to physical therapist
services with interventions that are appropriately designed
to match the patient’s irritability level.
67
Increased pain
may result if intervention intensity and selection are not
matched to the patient’s level of irritability.
? There are expenses associated with the provision of phys-
ical therapist services.
Future Research
There is a need for high-quality research studies that examine
the outcomes of physical therapist services for the man-
agement of patients with symptoms and functional deficits
related to GHOA. Comparisons should be made to placebo
treatment, to wait-and-see or no-treatment groups, and to
surgical interventions. Studies should be designed to deter-
mine the optimal frequency and duration of physical ther-
apist interventions. There is a need for prognostic cohort
studies to identify characteristics of patients who would most
benefit from nonoperative multimodal physical therapist-led
interventions for management of pain and functional deficits
associated with GHOA, including type and extent of glenoid
OA deformity, duration of symptoms, patient expectations,
and comorbidities.
Value Judgments
With the improvements noted in function, pain control, and
quality of life in an observational study, the GDG agreed that
the use of physical therapist services with interventions that
are appropriately designed to match the patient’s irritability
level is advisable.
Intentional Vagueness
Specific exercises are identified based on the examination
findings of the individual patient, including the associated
impairments and tissue irritability levels.
Exclusions
Thisquestiondidnotaddressefficacyofpreoperativephysical
therapist services; please refer to the preoperative physical
therapy best practice statement.
Quality Improvement
Organizations may use information provided by the patient,
care team documentation, imaging, and physical examination
to help develop nonoperative goals for physical therapist
services. Patient-rated outcomes of care should be assessed to
determine effectiveness and areas for improvement.
14 Physical Therapist Management of Glenohumeral Joint Osteoarthritis
Implementation and Audit
Organizationsmayauditoccurrenceofhistory,careteamdoc-
umentation, and prior imaging to help develop goals related
to nonoperative physical therapist intervention(s).
Nonoperative Physical Therapist Intervention
Options diamondsolid???
In the absence of high- or moderate-quality evidence, the
opinion of the GDG based on clinical expertise is that no one
specificinterventionperformedbyaphysicaltherapistissupe-
rior to another for patients with GHOA. Evidence Quality:
insufficient; Recommendation Strength: best practice.
Action Statement Profile
Aggregate Evidence Quality: 0 included studies.
Rationale
No literature exists comparing physical therapist interven-
tions for patients with GHOA. In the absence of evidence,
intervention selection should be guided by best available
evidence, clinical expertise, and patient values. In addition,
intervention selection should be guided by the individual
patient evaluation and their goals. Patient-reported outcomes
should be used to assess function and disability and to aid in
determining the effectiveness of treatment.
Nonoperative management for GHOA can include, but is
not limited to, NSAIDs, local injections, and physical thera-
pist management. A case series of 129 patients with GHOA
investigated the effects of a multimodal management of phys-
ical therapy, NSAIDs, injections (cortisone and/or sodium
hyaluronate), and education approach.
29
Physical therapist
services consisted of ROM and strength-training exercises
delivered by a physical therapist. Outcomes of pain, function,
and overall quality of life improved at 6 and 12 months and
remained at 3-year long-term follow-up. This study suggests
that 12 months of conservative care before determining if
shoulderarthroplastyisappropriateforapatientwithGHOA.
Expert opinion indicates that physical therapy for patients
with GHOA is often effective in decreasing pain, restoring
function, and obviating the need for surgical intervention.
63
Potential Benefits, Risks, Harms, and Costs of
Implementing this Recommendation
Benefits are as follows:
? Improved symptoms/pain, muscle performance, ROM,
and functional patient-reported outcomes
Risk, harms, and/or costs are as follows:
? There are potential harms of ongoing use of NSAIDs and
repeated injections.
Future Research
Future studies should determine the dose, parameters, effec-
tiveness, and outcomes of physical therapist interventions for
patients with GHOA. Studies should characterize parameters
and dose of interventions delivered to determine the optimal
physical therapist services to include interventions, length
of treatment, and delivery of care. In addition, comorbidi-
ties, psychosocial status, and functional demands should be
assessed to determine the impact on outcomes.
Value Judgments
Reducing pain through nonpharmaceutical means may be
more beneficial to the quality of life of individuals with
GHOA and may reduce the need for costly surgery and or
pharmaceuticals.
Intentional Vagueness
Physical therapist interventions should be based on individual
patient needs and impairments.
Exclusions
Patients already scheduled for a TSA were excluded.
Quality Improvement
Organizations may use information provided by the patient,
care team documentation, imaging, and physical examination
to help develop a nonoperative plan of care for physical thera-
pistservices.Patient-ratedoutcomesofcareshouldbeassessed
to determine effectiveness and areas for improvement.
Implementation and Audit
Organizations may track types of plans of care that achieve
the most effective and efficient outcomes for the patients
with GHOA.
Postoperative Physical Therapy Outcomes
diamondsolid???
In the absence of high- or moderate-quality evidence, the
opinion of the GDG based on clinical expertise is that phys-
ical therapist services delivered postoperatively may bene-
fit patient-rated functional outcomes in the management of
patientswhohaveundergoneTSAforGHOA.EvidenceQual-
ity: insufficient; Recommendation Strength: best practice.
Action Statement Profile
Aggregate Evidence Quality: 1 low-quality study.
59
Rationale
One low-quality study examined outcomes of physical ther-
apist services after TSA. Physical therapy services were com-
pared with a physician-guided home exercise program, with
no differences found in functional outcomes or patient sat-
isfaction between groups.
59
This study was a low-quality
retrospective study examining 2 cohorts treated during dif-
ferent time periods; it did not control for exercise volume or
measure compliance to treatment. A recent systematic review
of outcomes of TSA
5
provided no additional evidence. AAOS
recommends that formal physical therapist management be
considered for patients following TSA.
62
Potential Benefits, Risks, Harms, and Costs of
Implementing this Recommendation
Benefits are as follows:
? Earlier improvements and optimized outcomes of pain,
ROM, and function.
? Earlier detection of postsurgical complications including
infection.
Risks, harms, and/or costs are as follows:
Michener et al. 15
? There was no difference in outcomes compared with self-
directed or physician-directed management.
? There are expenses associated with the provision of phys-
ical therapist services.
Future Research
High-quality studies are needed to characterize the outcomes
of postoperative physical therapist management following
TSA for GHOA. Comparisons should be made for self-
directed or physician-directed home exercise programs,
controlling for the volume of exercise. Given the variety
of protocols that guide postoperative management of TSA,
studies should determine optimal timing to initiate ROM
to preserve the integrity of healing structures such as the
subscapularis, frequency and duration of physical therapist
treatments, and which interventions best improve shoulder
motion and function after TSA. Prognostic cohort studies
are needed to identify characteristics of patients who would
benefit from formal physical therapist intervention over a
home exercise program following TSA for GHOA. Given
the advances in telehealth technology, studies that examine
differences in delivery methods of physical therapist services
are also needed.
Value Judgments
Physical therapist supervision of patients may be appropriate
after TSA for GHOA; however, additional research may help
identify which individuals may succeed with a less-structured
rehabilitation program.
Intentional Vagueness
Given the lack of published research,the GDG cannot recom-
mend the amount or extent of physical therapist supervision
for optimal outcomes following TSA for GHOA. Patient
preferences,comorbidities,andspecificfunctionalneedslikely
impact individual patient needs for supervision.
Exclusions
This question did not address efficacy of physical therapist
services for the nonoperative or conservative management
of GHOA; please refer to the nonoperative and conservative
physical therapist management best practice statements.
Quality Improvement
Organizations may use documentation of relevant outcomes
to include ROM, functional status, and patient-reported out-
comesofpainanddisabilitywithphysicaltherapistsupervised
care and nonsupervised care provided in the postoperative
management of patients with TSA for GHOA.
Implementation and Audit
Organizations may audit outcomes of care with physical
therapist–supervised care versus nonsupervised care provided
in the postoperative management of patients with TSA
for GHOA.
Postoperative Physical Therapist Management
of Edema diamondsolid???
In the absence of high or moderate quality evidence, the
opinionoftheGDGisthatphysicaltherapistinterventionsfor
edemainpatientswhohaveundergoneTSAforGHOAshould
be based on best available evidence, clinical expertise, and
patient values. Evidence Quality: insufficient; Recommenda-
tion Strength: best practice.
Action Statement Profile
Aggregate Evidence Quality: 0 included studies.
Rationale
Edema after injury or surgery is important to manage to
optimize patient outcomes. Commonly used interventions
such as ice, compression, and elevation may be effective to
manage swelling. Prolonged edema can interfere with the
healing process. A systematic review concluded various lym-
phatic therapies can be effective in those with prolonged
or extensive edema, pain, and/olimitations.
69
The addition
of manual lymphatic drainage may assist lymphatic system
function by promoting variations in interstitial pressures and
should be considered in reduction of prolonged edema.
70,71
Potential Benefits, Risks, Harms, and Costs of
Implementing this Recommendation
Benefits are as follows:
? A program for management of swelling and edema may
assist in pain management and reduce secondary compli-
cations that can result from prolonged edema that delays
the healing process.
Risks, harms, and/or costs are as follows:
? Using interventions that manage swelling and edema
has shown no risk or harm to patients, and the overall
cost to health care may be lowered by reducing the
secondary complications that could occur with prolonged
healing.
Future Research
Prior evidence
69–71
indicates swelling can negatively impact
healing. Studies are needed to determine the effectiveness of
treatment for edema management in patients after TSA. In
addition, a focus on which interventions are most effective
for patient outcomes is needed. Questions could consider if
theconventional useofice,compression,andelevationimpact
edemaandpatientoutcomes,oriftheuseofmanuallymphatic
drainage techniques would be beneficial.
Value Judgments
With no studies available, and given the known impact of
swelling on healing,
69–71
management of the swelling should
be considered as part of the postoperative plan of care for
patients who have undergone a TSA.
Intentional Vagueness
Type of edema control is not identified.
Exclusions
No exclusions were noted.
Quality Improvement
Organizations may use information provided by the patient,
care team documentation, imaging, and physical examina-
tion to help determine the impact of edema management on
patient-reported outcomes.
16 Physical Therapist Management of Glenohumeral Joint Osteoarthritis
Implementation and Audit
Organizations may use the data of patient outcomes to deter-
mine future interventions for patients with GHOA after TSA.
Revision Plans
This CPG represents a cross-sectional view of current man-
agement strategies and may become outdated as new evidence
becomes available. This CPG will be revised in accordance
with new evidence, changing practice, rapidly emerging treat-
ment options, and new technology; reaffirmed; or withdrawn
in 5 years.
Dissemination Plans and Implementation
Tools
The primary purpose of this CPG is to provide interested
readers with full documentation of the best available evi-
dence for various intervention strategies associated with the
physical therapist management of GHOA and TSA. Publi-
cation of this CPG will be announced by press release and
published in PTJ: Physical Therapy & Rehabilitation Journal,
the journal of APTA. This CPG is available in Spanish; see
Supplementary Appendix 8.
Education and implementation tools for this CPG will be
disseminated via online resources,such as webinars,podcasts,
pocket guides (https://www.guidelinecentral.com/aptamembe
rs/), and continuing education courses, at professional annual
meetings, and via social media. A CPG+, which includes an
appraisal rating using the AGREE II tool, highlights, a check-
your-practice section, and review comments, is available on a
pta.org forthisCPGat:https://www.apta.org/patient-care/e
vidence-based-practice-resources/cpgs/physical-therapist-ma
nagement-of-glenohumeral-joint-osteoarthritis. Additional
implementation tools will be forthcoming.
Disclaimer
This clinical practice guideline was developed by an APTA
volunteer guideline development group consisting of physical
therapists, an occupational therapist, and a physician. It was
based on systematic reviews of current scientific literature,
clinical information, and accepted approaches to the physical
therapist management of glenohumeral joint osteoarthritis.
This clinical practice guideline is not intended to be a fixed
protocol,as some patients may require more or less treatment.
Clinical patients may not necessarily be the same as partic-
ipants in a clinical trial. Patient care and treatment should
always be based on a clinician’s independent medical judg-
ment, given the individual patient’s clinical circumstances.
Author Contributions
Concept/idea/research design: L.A. Michener, L.D. Abbruzzese,
S.L. Bondoc, H. Kosakowski, B.G. Leggin, A.M. Lucado, A.L. Seitz.
Writing: L.A. Michener, J. Heitzman, L.D. Abbruzzese, K. Bowne,
P.T. Henning, H. Kosakowski, B.G. Leggin, A.M. Lucado, A.L. Seitz.
Data analysis: L.A. Michener, J. Heitzman, P.T. Henning, A.M. Lucado,
A.L. Seitz.
Project management: L.A. Michener, J. Heitzman, H. Kosakowski.
Consultation (including review of manuscript before submitting):
L.A. Michener, J. Heitzman, S.L. Bondoc, K. Bowne, A.M. Lucado,
A.L. Seitz.
L.A. Michener and J. Heitzman are co-first authors.
Acknowledgments
Danielle Schulte, MS, of the American Academy of Orthopaedic Sur-
geons, provided data collection.
Funding
This clinical practice guideline was funded exclusively by APTA, which
received no funding from outside commercial sources to support its
development.
Data Availability Statement
Supplementaryfilescontaindatausedforthisclinicalpracticeguideline.
Additional data elements are available upon request. Peer review com-
ments are available, upon reasonable request, from practice@apta.org.
Disclosures
In accordance with APTA policy, and prior to the development of this
CPG, all individuals whose names appear as authors or contributors to
this CPG filed a disclosure statement as part of the submission process.
All panel members provided full disclosure of potential conflicts of
interest prior to voting on the recommendations contained within this
clinical practice guideline. They also disclosed potential conflicts of
interest in writing to the American Academy of Orthopaedic Surgeons
via a private online reporting database and verbally at the recommen-
dation approval meeting.
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