Perspective

Staged Approach for Rehabilitation

Classification: Shoulder Disorders
(STAR–Shoulder)

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Philip W. McClure, Lori A. Michener
P.W. McClure, PT, PhD, FAPTA,
Department of Physical Therapy,
Shoulder disorders are a common musculoskeletal problem causing pain and func-
Arcadia University, 450 S Easton
tional loss. Traditionally, diagnostic categories are based on a pathoanatomic medical Rd, Glenside, PA 19038 (USA).
model aimed at identifying the pathologic tissues. However, the pathoanatomic Address all correspondence to
model may not provide diagnostic categories that effectively guide treatment decision Dr McClure at: mcclure@
making in rehabilitation. An expanded classification system is proposed that includes arcadia.edu.
the pathoanatomic diagnosis and a rehabilitation classification based on tissue irrita- L.A. Michener, PT, PhD, ATC, SCS,
bility and identified impairments. For the rehabilitation classification, 3 levels of Division of Biokinesiology and
irritability are proposed and defined, with corresponding strategies guiding intensity Physical Therapy, University of
Southern California, Los Angeles,
of treatment based on the physical stress theory. Common impairments are identified
California.
and are used to guide specific intervention tactics with varying levels of intensity. The
proposed system is conceptual and needs to be tested for reliability and validity. This [McClure PW, Michener LA.
Staged approach for rehabilitation
classification system may be useful clinically for guiding rehabilitation intervention
classification: shoulder disorders
and provides a potential method of identifying relevant subgroups in future research (STAR–Shoulder). Phys Ther.
studies. Although the system was developed for and applied to shoulder disorders, it 2015;95:791– 800.]
may be applicable to classification and rehabilitation of musculoskeletal disorders in
© 2015 American Physical Therapy
other body regions. Association

Published Ahead of Print:

December 11, 2014
Accepted: November 25, 2014
Submitted: April 14, 2014

Post a Rapid Response to

this article at:
ptjournal.apta.org

May 2015 Volume 95 Number 5 Physical Therapy f 791

Staged Approach for Rehabilitation of Shoulder Disorders

S
houlder disorders are a com- symptoms often change across an rehabilitation to resemble those of
mon musculoskeletal problem1 episode of care, which requires mod- patient B, with specific impairments
causing pain and functional ification of the intervention and may to be accurately identified and
loss. Traditionally, diagnostic catego- change the prognosis. The pathoana- treated. In both cases, the pathoana-
ries are based on a pathoanatomic tomic model also implies that the tomic diagnosis of rotator cuff tendi-
medical model aimed at identifying pathology explains patient symp- nopathy could be supported and
the pathologic tissues. Much work toms and disability (activity limita- remain accurate over the episode of
has been published regarding diag- tions and participation restrictions) care; however, specific pain, symp-
nostic accuracy of the history and and that correcting the pathology toms, and impairments dictate very
physical examination tests2 used to will improve the symptoms and dis- different rehabilitation strategies and
diagnose patients with shoulder dis- ability. Although the pathoanatomic interventions.
orders. However, the pathoanatomic system of diagnosis may be very

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model may not provide diagnostic appropriate for surgical decision Pathoanatomic classification may par-
categories that effectively guide making, it may be inadequate for tially enable rehabilitation decision
treatment decision making in reha- guiding rehabilitation.3 Pathoanat- making through the application of
bilitation.3,4 Recent evidence sug- omic diagnostic categories may tissue-healing principles that guide
gests a poor relationship between encompass patients with similar tis- treatment decisions and prognosis for
diagnostic label and chosen rehabili- sue pathology, but within each shoulder disorders. For example, the
tation interventions among orthope- pathoanatomic category, there likely pathoanatomic diagnosis of adhesive
dic physical therapists.5 We believe exists a heterogeneous group of capsulitis indicates treatment to
an alternative classification could be patients who have different or vary- restore shoulder ROM and that recov-
more relevant and useful for specifi- ing degrees of impairment (loss of ery is typically protracted over
cally guiding rehabilitation. The pur- body structure and function) and months.6 However, it does not indi-
pose of this article is to propose a pain that warrant different rehabili- cate which shoulder motions are
new classification system that tation strategies. impaired, nor does it indicate the
expands upon the traditional patho- appropriate intensity of treatment.
anatomic diagnostic classification to To illustrate, consider 2 patients Likewise, knowing a patient has sus-
guide rehabilitation. This expanded accurately diagnosed pathoanatomi- tained a Bankart lesion of the anterior
classification is designed to match cally with “rotator cuff tendinopa- labrum would suggest an initial period
rehabilitation interventions to thy” based on impingement tests, a of limiting external rotation ROM but
patient subgroups and stages to facil- painful arc, and pain with isometric would not fully inform rehabilitation
itate more effective care. resistive testing but who present interventions directed toward poten-
very different pain and impairments. tial concomitant impairments such as
In the traditional medical model, Patient A, with high levels of acute weakness or poor scapular control.
musculoskeletal shoulder disorders pain following a recent period of Inconsistent relationships between tis-
are classified based on a pathoanat- overuse, would likely be managed sue pathology and impairments3,7–10
omic diagnosis to guide decisions for with activity modification, ice, anti- limit the sole use of pathology for clin-
treatment and prognosis. Examples inflammatory medication, and pain- ical decision making in rehabilitation.
of these diagnoses are rotator cuff free range-of-motion (ROM) exer- The pathoanatomic diagnosis alone
tear or tendinopathy, adhesive cap- cise, with consideration of a cannot fully direct the intensity and
sulitis, glenohumeral anterior insta- subacromial injection. Patient B, specific intervention tactics used in
bility, and superior labral anterior- with chronic low-level pain brought the treatment of patients with muscu-
posterior (SLAP) lesions. The on mainly by prolonged or strenuous loskeletal shoulder disorders.3,4,11 We
pathoanatomic diagnosis infers that overhead activity, shows primary propose a classification system that
patients with the same tissue pathol- impairments of posterior shoulder includes the pathoanatomic diagnosis
ogy form a homogeneous group. tightness and scapular muscle weak- but is expanded to consider tissue irri-
Also implicit in this model is that ness. This patient would likely be tability and individual impairments.
patients with the same pathology managed very differently, with an We believe the concepts of tissue irri-
should be managed in the same way emphasis on frequent and prolonged tability and identification of specific
and have similar prognoses and that posterior shoulder stretching and impairments, integrated with available
the diagnosis remains static over an scapular muscle strengthening with knowledge of the patient’s patho-
episode of care. However, clinicians resistance to fatigue. Additionally, anatomy, can be used to more effec-
guiding patients through rehabilita- patient A’s signs and symptoms tively guide rehabilitation. Moreover,
tion are well aware that signs and might change over an episode of this expanded classification system

792 f Physical Therapy Volume 95 Number 5 May 2015

 Staged Approach for Rehabilitation of Shoulder Disorders

Complaint of “Shoulder Symptom”

Level 1: Screening
History, Basic Physical Examination, Red or Yellow Flags

Appropriate for
Appropriate for Physical Therapy Not Appropriate for
Physical Therapy and Referral Physical Therapy

Level 2: Pathoanatomic Diagnosis

Specific Physical Examination

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Shoulder Origin of Symptoms Nonshoulder Origin of Symptoms

Subacromial Pain Glenohumeral

Adhesive Capsulitis Other
Syndrome Instability

Level 3: Rehabilitation Classification

(1) Tissue Irritability (Guides Intensity of Physical Stress)
(2) Impairments (Guides Specific Intervention Tactics)

High Irritability and Moderate Irritability and Low Irritability and

Identified Impairments Identified Impairments Identified Impairments

Figure.
Overall system for classification incorporating screening, pathoanatomic diagnosis, and rehabilitation classification. The specific
pathoanatomic diagnoses shown at level 2 are only given as common examples; these are not meant to represent a complete list.
For clarity, pathoanatomic diagnosis and rehabilitation classification are listed sequentially. However, they both are derived primarily
from the history and physical examination and, in practice, likely occur in parallel rather than sequentially.

could facilitate improved outcomes based classification systems that go clinical commentary is to propose a
and reduce overall health care costs. beyond a pathoanatomic diagnosis staged approach for rehabilitation
have been developed for neck and classification system for shoulder
Classification systems primarily aim low back pain,13,14 with patients sub- pain (STAR–Shoulder). We propose a
to guide treatment decision making grouped based on their history, staged approach to classification that
and inform prognosis. Additionally, impairments, and specific symptom- includes: (1) screening, (2) patho-
diagnostic categories are important atic responses to mechanical stress. anatomic diagnosis, and (3) a reha-
for communication among payers, Evidence indicates improved patient- bilitation classification based on
health care providers, researchers, rated outcomes when patients irritability rating and primary impair-
and those utilizing research findings. received the treatment matched to ments (Figure). We also propose a
In order to accomplish these various their category of classification com- system that matches intervention
goals, a classification system should pared with patients who did not strategies and tactics with the cate-
have mutually exclusive categories receive the matched treatment for gories of classification. The rehabili-
that identify subgroups within a neck and low back pain.15,16 Further- tation classification of patients based
patient population that require a more, cost of care for rehabilitation on tissue irritability and impairments
unique treatment approach. There was lower in those receiving enables the development of a
are multiple classification systems matched treatment.17 Rehabilitation directed rehabilitation treatment
for the shoulder, but they lack rele- guided by classification systems, or program.
vant categories to guide rehabilita- stratified care,18,19 can improve
tion, the categories are not mutually patient-rated outcomes and reduce
exclusive, and they are largely based immediate and downstream health
on pathology.5,12 Specific treatment- care costs.20 –23 The purpose of this

May 2015 Volume 95 Number 5 Physical Therapy f 793

Staged Approach for Rehabilitation of Shoulder Disorders

Staged Approach to Table 1.

Classification Potential Red Flag Conditions for the Shoulder (Modified From Mitchell et al25)
Overview Potential Condition History and Examination Findings
After appropriate screening, the Tumor History of cancer
pathoanatomic diagnosis is used to Symptoms and signs of cancer, including unexplained weight loss, pain
classify patients in the staged classi- not correlated with mechanical stress, and unexplained fatigue
Unexplained mass, swelling, or deformity
fication system. This diagnosis is
derived from a combination of his- Infection Red skin
Fever
tory, specific special tests, and Systemically unwell
results of imaging if available. Evi- Fracture or unreduced Significant trauma
dence from systematic reviews and dislocation Seizure
practice guidelines20 –23 indicate that Acute disabling pain

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Acute loss of motion
recommended interventions are Deformity or loss of normal contour
often similar for some pathoana-
Neurologic lesion Unexplained sensory or motor deficit
tomic diagnoses of the shoulder. The
rehabilitation classification is used to Visceral pathology Pain not reproduced with shoulder mechanical stress
Pain or symptoms with physical exertion or respiratory stress
guide the intensity and specific focus Pain associated with gastrointestinal symptoms
of rehabilitation. The intensity of the Scapular pain associated with ingestion of fatty foods
rehabilitation program is based on
the level of tissue irritability, and spe-
cific interventions are selected based sion of red flag screening is beyond naire have demonstrated a relation-
on observed key impairments (ie, the scope of this article, Mitchell et ship to a longer recovery, chronic
those hypothesized to relate to the al25 suggested a basic list of ele- symptoms, and work loss in patients
patient activity limitations and par- ments, including tumor, infection, with shoulder pain.27–29 History and
ticipation restrictions). For clarity, acute trauma suggesting fracture or physical examination findings obtai-
pathoanatomic diagnosis and reha- dislocation, and unexplained neuro- ned during screening also are used to
bilitation classification are depicted logic symptoms (Tab. 1). We have aid subsequent classification in level
sequentially (Figure). However, they added pain of visceral origin to this 2 (pathoanatomic diagnosis) and
both are derived primarily from the list proposed by Mitchell and col- level 3 (rehabilitation classification).
history and physical examination leagues. Examples of shoulder pain
and, in practice, are likely derived in of visceral origin include gall bladder Level 2–Pathoanatomic Diagnosis
parallel rather than sequentially. and cardiac pathology. Goodman26 The pathoanatomic diagnosis is
described a more extensive screen- made based on identifying the pre-
Level 1–Screening ing approach and emphasized the sumed tissue pathology generating
Screening includes taking a history possibility of referred pain from car- the symptoms. The history and phys-
and performing a basic physical diopulmonary structures and the ical examination findings from level
examination to gain a general thoracic viscera. 1 are used along with the results of
impression of the problem and iden- tissue-based special tests as well as
tify potential “red flags” and “yellow Screening for yellow flags is per- any imaging procedures to make a
flags.” For red flags, the history and formed to determine psychosocial pathoanatomic diagnosis. The first
physical examination findings are issues such as passive coping style, step is to verify that the symptoms
used to determine if there are signs pain catastrophizing, fear of move- are attributable to shoulder pathol-
and symptoms consistent with a ment, and general psychological dis- ogy rather than referred pain from a
musculoskeletal problem amenable tress that can affect rehabilitation. more proximal source such as the
to rehabilitation rather than a more Specifically, these factors may affect cervical spine or thoracic outlet.30
serious disorder requiring further outcome of care, how treatment Distribution of symptoms, cervical
assessment and medical care.24 –26 interventions are delivered, and spine rotation ROM, Spurling test,
Critical to the screening is the iden- direct specific patient education and neural tension tests are the most
tification of red flags that may indi- strategies. Patients with these factors helpful examination findings for dis-
cate a serious pathology such as a also may be indicated for a direct tinguishing cervical spine pain.31,32
tumor or infection that requires referral for treatment by other health Although these more proximal prob-
referral to an appropriate health care care providers. Elevated scores on lems may still be amenable to reha-
professional. Although a full discus- the Tampa Kinesiophobia Scale and bilitation, they are beyond the scope
Fear-Avoidance Beliefs Question- of the STAR–Shoulder.

794 f Physical Therapy Volume 95 Number 5 May 2015

 Staged Approach for Rehabilitation of Shoulder Disorders

Table 2.
Examples of Common Pathoanatomic Diagnoses Based on History and Physical Examination Findings

Other Common
Measure Subacromial Pain Syndrome Adhesive Capsulitis Glenohumeral Instability Diagnoses

Key positive findings Impingement signs (Neer, Hawkins, Spontaneous progressive pain Age usually ⬍40 y Postoperative
“rule in”: Jobe tests) Loss of motion in multiple History of dislocation or Glenohumeral arthritis
Painful arc planes: external rotation subluxation Fractures
Pain with isometric resistance most limited Apprehension test Acromioclavicular joint
Weakness Pain at end-range of motion Relocation test Neural entrapment
Atrophy (tear) Generalized laxity Myofascial pain
Fibromyalgia

Key negative findings Significant loss of motion Normal motion No history of dislocation or
“rule out”: Instability signs Age ⬍40 y subluxation

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No apprehension with testing

The findings from the basic physical because surgical intervention is ary instability, and SLAP lesions. The
examination performed during the designed to address specific ana- current use of such a large number
screening are used along with a vast tomic pathologies. Although specific of pathoanatomic diagnostic catego-
array of available special tests to indications for a surgical rather than ries that are not easily differentiated
attempt to identify the specific tis- a nonsurgical approach are often by a physical examination is imprac-
sues responsible for shoulder symp- unclear and the subject of consider- tical and likely does not facilitate
toms. As examples, the key positive able debate,23 this level is where that treatment decision making for
and negative findings associated decision occurs. Entities such as rehabilitation.
with the most common shoulder acute or traumatic full-thickness rota-
pathologies are shown in Table 2. tor cuff tears, recurrent glenohu- Level 3–Rehabilitation
Although many diagnostic accuracy meral dislocations in younger active Classification/Tissue irritability
studies have been performed for var- patients, or severe glenohumeral and Impairments
ious special tests and pathologies, arthritis often can be managed suc- The rehabilitation categories are based
there is considerable variation in cessfully with surgery.33–37 How- on the stage of tissue irritability to
findings among studies.2 We selected ever, some patients with clearly guide the intensity of treatment, and
tests to define each category based proven tissue deficits such as partial- impairments are used to guide the
on current evidence.2 It is important or full-thickness rotator cuff tears selection of specific rehabilitation
to note that most of the diagnostic may respond well without surgical techniques. The concept of tissue “irri-
accuracy studies performed on spe- intervention.38 Future research iden- tability” is meant to reflect the tissue’s
cial tests of the shoulder use either tifying specific characteristics pre- ability to handle physical stress and
imaging or direct visualization dur- dicting success with surgical or non- theoretically relates to its physical sta-
ing surgery as a gold standard in surgical intervention will be im- tus and the degree of inflammatory
determining accuracy. Therefore, portant to improving classification. activity present. Three phases of irrita-
the gold standard is based on identi- bility, developed by consensus,6 are
fied tissue pathology rather than The tissue-based, pathoanatomic operationally defined in Table 3 using
direct evidence that the pathologic medical diagnosis classification of pain levels, the relationship between
tissue is actually producing the musculoskeletal shoulder pain has a pain and motion, and self-report of dis-
symptoms. Imaging procedures such large number of categories consist- ability. These irritability stages are
as radiography, ultrasound, and mag- ing of a single diagnosis or a combi- meant to be mutually exclusive and,
netic resonance imaging also would nation of diagnoses.11 We have cho- therefore, are the primary means of
fit with this level of diagnosis, as they sen to illustrate only a few of the classifying at this level. The physical
help to directly identify tissue most common entities seen by phys- intensity of intervention can then be
pathology. ical therapists as examples. The cat- directly matched to the stage of irrita-
egory of “subacromial pain syn- bility. We intentionally did not include
One of the primary intervention drome” is particularly challenging3 specific thresholds for each disability
decisions made at this level is sur- and includes common pathoana- criterion for tissue irritability using
gery versus nonsurgery, which may tomic labels such as subacromial patient-rated outcome instruments, as
include medication, corticosteroid impingement, bicipital tendinopa- there is no single standard accepted
injection, rest, and rehabilitation. thy, rotator cuff tendinopathy and patient-rated outcome instrument and
This is an appropriate decision point tears, subacromial bursitis, second- no current basis for specific thresh-

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Staged Approach for Rehabilitation of Shoulder Disorders

Table 3.
Operational Definitions for 3 Stages of Tissue Irritability Derived by Consensusa

Stage of Irritability

High Moderate Low

History and examination findings High pain (ⱖ7/10) Moderate pain (4–6/10) Low pain (ⱕ3/10)
Consistent night or rest pain Intermittent night or rest pain Absent night or rest pain
Pain before end of ROM Pain at end of ROM Minimal pain with overpressure
AROM⬍PROM AROM⬃PROM AROM⫽PROM
High disability Moderate disability Low disability

Intervention focus Minimize Physical Stress Mild–Moderate Physical Stress Moderate–High Physical Stress
Activity modification Address impairments Address impairments
Monitor impairments Basic-level functional activity restoration High-demand functional activity restoration

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a
ROM⫽range of motion, AROM⫽active range of motion, PROM⫽passive range of motion.

olds. We hope to encourage identifi- Further specific guidance in rehabil- tion of the patient with glenohu-
cation of thresholds through appropri- itation is based on identified impair- meral laxity. Likewise, 2 patients
ate future research. ments that are deemed relevant reporting high pain levels would
because they are believed to either likely be approached differently if
Tissue irritability staging is useful in perpetuate the pathology or cause the history and physical examination
guiding rehabilitation that aims to functional loss and disability. Table 4 suggest actual tissue injury in one
place the appropriate physical stress describes common shoulder impair- patient versus high fear avoidance
on the tissue at each stage. Patients ments and the associated matched and psychological distress in the
with high irritability are not ready for treatment strategies. Impairment cat- other patient. Although a standard
significant physical stress to the egories are not mutually exclusive, “one size fits all” rehabilitation pro-
affected tissues. Therefore, the treat- and a specific patient may have mul- tocol is the cleanest approach in
ment would emphasize activity mod- tiple impairments; therefore, impair- terms of research methodology,39 – 43
ification and appropriate modalities, ments should be considered only as a it is unlikely to yield optimal out-
medication, and manual therapy to secondary means of classification. A comes unless very similar impair-
relieve pain and inflammation, with full explanation of how best to iden- ments across all patients can be
only low levels of physical stress via tify each of these impairments in an assumed.
exercise. Patient education during examination is beyond the scope of
this stage would typically emphasize this article. However, we think the Discussion
how to avoid harmful stress to the list given in Table 4 captures the The STAR classification system is
affected tissues while maintaining common impairments related to founded with the pathoanatomic
appropriate stress to uninvolved tis- shoulder dysfunction that are used to diagnosis and then is expanded to
sues. The treatment strategy for select appropriate rehabilitation aid rehabilitation treatment decision
patients with moderate irritability is interventions. Identifying impair- making by classifying the level of irri-
controlled physical stress in the form ments is an essential part of the tability and identification of impair-
of progressive manual therapy, mild examination because patients with ments. Although we have argued
stretching and motor control exer- the same pathoanatomic diagnosis that the rehabilitation classification
cises, and basic functional activity. and level of irritability may have dif- is essential for guiding specific reha-
The low irritability category fering impairments and, therefore, bilitation, we believe the pathoanat-
describes those patients who have require different intervention strate- omic diagnosis is still an essential ele-
little pain and whose tissues are gies. For example, one patient may ment of the process. Consider, for
ready for progressive physical stress have “subacromial pain syndrome” example, 3 patients with a primary
in the form of stretching, manual associated with glenohumeral laxity, impairment of limited glenohumeral
therapy, resistive exercise, and and another patient may have the mobility attributed to capsular
higher-demand physical activity. Cat- same “subacromial pain syndrome” changes. Patient 1 is 30 years old and
egorizing the stage of tissue irritabil- with a posterior shoulder contrac- 8 weeks post-proximal humeral frac-
ity enables the selection of a ture. Stretching in various forms ture, patient 2 is 50 years old with
matched intervention intensity. would be critical to the latter patient early-stage adhesive capsulitis, and
but would likely worsen the condi- patient 3 is 70 years old with chronic

796 f Physical Therapy Volume 95 Number 5 May 2015

 Staged Approach for Rehabilitation of Shoulder Disorders

Table 4.
Common Shoulder Impairments Associated With Progressively Intensive Intervention Tactics Across a Spectrum of Tissue
Irritabilitya
Impairment High Irritability Moderate Irritability Low Irritability

Pain associated with local tissue Activity modification Activity modification No modalities
injury Manual therapy Manual therapy
Modalities Limited modality use

Pain associated with central Progressive exposure to activity

sensitization Medical management

Limited passive mobility: ROM, stretching, manual therapy: ROM, stretching, manual therapy: ROM, stretching, manual therapy:
joint/muscle/neural tissues pain-free only, typically non–end- comfortable end-range stretch, tolerable stretch sensation at
range typically intermittent end-range, typically longer
duration and frequency

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Excessive passive mobility Protect joint or tissue from end-range Develop active control in mid- Develop active control during full-
range while avoiding end-range range, high-level functional
in basic activity activity
Address hypomobility of adjacent Address hypomobility of adjacent
joints or tissues joints or tissues

Neuromuscular weakness AROM within pain-free ranges Light or moderate resistance to Moderate or high resistance to
associated with atrophy, disuse, fatigue fatigue
and deconditioning Mid-ranges Include end-ranges

Neuromuscular weakness AROM within pain-free ranges Basic movement training with High-demand movement training
associated with poor motor Consider use of biofeedback, emphasis on quality/precision with emphasis on quality rather
control or neural activation neuromuscular electrical stimulation, rather than resistance according than resistance according to
or other activation strategies to motor learning principles motor learning principles

Functional activity intolerance Protect joint or tissue from end-range, Progressively engage in basic Progressively engage in high-
encourage use of unaffected regions functional activity demand functional activity

Poor patient understanding leading Appropriate patient education Appropriate patient education Appropriate patient education
to inappropriate activity (or
avoidance of activity)
a
ROM⫽range of motion, AROM⫽active range of motion.

pain and stiffness due to glenohu- 3 months. Likewise, a patient labeled prognosis and be more readily en-
meral arthritis identified radiograph- as having “subacromial pain syn- couraged to explore surgical options
ically. The rehabilitation strategy for drome” with a known rotator cuff if not responding to rehabilitation.
all 3 patients would likely be similar, tear might be managed similarly in Hence, patient management and pro-
namely to impart physical stress to rehabilitation to a patient with tendi- gnosis could vary substantially based
the glenohumeral joint in the form of nopathy and no tear based on iden- on the pathology present despite
active and passive stretching and tified impairments (eg, shoulder wea- having similar impairments. Table 5
manual therapy consistent with the kness). However, the patient with a summarizes essential features of
stage of irritability. However, the known tear might have a poorer
expected time course of recovery
and prognosis would likely be very
different based on the pathoanat-
Table 5.
omic diagnosis. Patient 1 would be Comparison of Features Between Pathoanatomic Diagnosis and Rehabilitation
expected to recover the majority of Classification
ROM within 3 to 4 months postin-
Pathoanatomic Diagnosis Rehabilitation Classification
jury, whereas patient 2 would be
expected to recover motion much Identifies primary tissue pathology Identifies level of irritability and key impairments

more slowly over a period of 1 to 2 Remains stable across an episode of care Typically changes over an episode of care
years. Patient 3 may recover motion Guides a general treatment strategy Guides specific rehabilitation intervention
with rehabilitation but would likely ● Surgery or nonoperative care? ● Appropriate intensity of physical stress?
● Key tissue and movement ● Key impairments driving symptoms and loss
be offered a surgical option of total precautions? of function?
shoulder replacement if not making
Informs prognosis May inform prognosis
satisfactory improvement within 2 to

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Staged Approach for Rehabilitation of Shoulder Disorders

both the pathoanatomic diagnosis with largely positive feedback. The for initial intervention. Other clini-
and rehabilitation classification. belief is that this classification cap- cally determined features such as the
tures the thought process used by most distal extent of perceived pain
We believe postoperative conditions experienced clinicians. Another fea- or the nature of the end-feel with
fit nicely within this system. In the ture is that the STAR simply expands passive ROM may prove useful in
postoperative patient, the pathoana- the current, prevailing pathoanat- determining irritability level. Cur-
tomic diagnosis is quite clear and omic model. Therefore, it is not sep- rently, the relationships among tis-
defined by which tissues have been arate from the predominant existing sue pathology, symptoms, and func-
debrided or repaired as well as the medical framework and does not tional loss at the shoulder are poorly
extent of the surgical repair (eg, require learning an entirely unique understood.
small full-thickness rotator cuff tear and novel system. Including the
repaired directly versus large or mas- pathoanatomic diagnosis in the sys- We have not offered specific opera-

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sive rotator cuff tear requiring sub- tem also facilitates communication tional definitions for each of the
stantial tissue mobilization). With a within the larger health care impairment categories delineated in
known tissue injury and repair, the community. Table 4. These definitions need to be
irritability rating and corresponding developed based on history and clin-
intensity of physical stress or protec- There are also several important lim- ical examination such that accurate
tion from stress would be more eas- itations to the STAR-Shoulder classi- data can be recorded regarding their
ily defined by known rates of tissue fication system. It clearly is only at a presence or absence in a specific
healing. The early postoperative conceptual stage and requires sys- patient. As more data become avail-
period would equate to high irritabil- tematic research to be refined and able, the categories and key impair-
ity with corresponding low levels of validated. Our criteria for irritability ments identified in this system may
physical stress and significant modifi- stages were only conceived by con- require modification. Likewise, our
cation of activity. Low irritability and sensus from a group of experienced knowledge about which patients are
end-stage rehabilitation would occur clinicians involved in clinical prac- best candidates for surgical and non-
when the tissue healing is believed to tice and research. The irritability surgical interventions will improve
be well established and able to tolerate classification is heavily based on pain and inform the STAR-Shoulder sys-
high levels of physical stress. reports to estimate the tissue’s ability tem. Another limitation of the sys-
to handle stress, which given the tem is that it is focused primarily on
There are several potentially attrac- complex nature of pain and potential physical examination and impair-
tive features of the proposed STAR– for central sensitization, may be ments and does not fully address
Shoulder classification system. problematic. Patients with central personal or environmental factors
Although this system was developed sensitization have amplified pain not identified in the International Clas-
to guide rehabilitation of shoulder proportional to tissue injury attrib- sification of Functioning, Disability
disorders, we believe the basic sys- uted to changes within the central and Health45 (ICF) model. These are
tem is conceptually simple and could nervous system. Recently, a consen- important aspects that often influ-
be widely applied to guide rehabili- sus document has been produced ence treatment decisions or out-
tation of other musculoskeletal dis- proposing specific criteria for identi- come and ultimately may need to be
orders in other regions. The concept fying patients with central sensitiza- incorporated.
of tissue irritability is independent of tion based on clinical examination44;
body region; however, appropriate patients with this condition may not Recommended Next Steps
operational definitions for high, fit the proposed STAR system well. It Several steps are necessary to evalu-
moderate, and low irritability would is likely that our criteria and opera- ate, refine, and validate the proposed
likely need to be developed for each tional definitions for each stage will model that we believe are readily
region. Also, this system has been need to be modified and refined. achievable over time with a system-
embraced by a group of experienced Likewise, it is possible that a mix of atic approach and collection of
clinicians and researchers represent- features used to define irritability appropriate data. These steps
ing a variety of geographical regions may be present, preventing a clean include:
of the United States, each with mul- exclusive classification. Although,
tiple publications related to shoulder ultimately, this issue could be 1. The reliability and validity of the
disorders. Likewise, we have pre- addressed by developing well- proposed definition for the irrita-
sented this system on multiple occa- validated criteria, in the meantime, bility classification need to be
sions to clinicians nationally and in we recommend using the more con- determined.
small groups in a variety of locations servative or higher irritability rating

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 Staged Approach for Rehabilitation of Shoulder Disorders

2. Standard operational definitions impairments guides specific tactics 9 McCabe RA, Nicholas SJ, Montgomery KD,
et al. The effect of rotator cuff tear size on
based on patient history and clin- used for intervention. Although shoulder strength and range of motion.
ical examination procedures need applied specifically to shoulder dis- J Orthop Sports Phys Ther. 2005;35:130 –
135.
to be developed for accurately id- orders, we believe the model may be
entifying each of the proposed im- useful in classifying musculoskeletal 10 Gill TK, Shanahan EM, Allison D, et al.
Prevalence of abnormalities on shoulder
pairments delineated in Table 4. disorders in other body regions. The MRI in symptomatic and asymptomatic
system is only at a conceptual stage, older adults. Int J Rheum Dis. 2014;17:
863– 871.
3. Specific treatment procedures and research is needed to evaluate,
11 Braman JP, Zhao KD, Lawrence RL, et al.
matched to defined impairments, refine, and validate the proposed Shoulder impingement revisited: evolu-
with operationally defined inten- model. tion of diagnostic understanding in ortho-
pedic surgery and physical therapy. Med
sity levels, need to be developed Biol Eng Comput. 2014;52:211–219.
such that the type of treatment

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Both authors provided concept/idea/project 12 Buchbinder R, Goel V, Bombardier C,
and intensity can be accurately design and writing. The authors acknowl- Hogg-Johnson S. Classification systems of
assessed. soft tissue disorders of the neck and upper
edge Martin Kelley, Amee Seitz, Mike Shaf- limb: do they satisfy methodological
fer, and Tim Uhl for their input into the early guidelines? J Clin Epidemiol. 1996;49:
4. The usefulness or validity of the development of the classification system pre- 141–149.
sented. They also acknowledge the helpful 13 Childs JD, Cleland JA, Elliott JM, et al.
irritability levels and specific input from a group assembled to create the Neck pain: clinical practice guidelines
impairments classification could National Orthopaedic Physical Therapy Out- linked to the International Classification
be judged in studies comparing comes Database for the shoulder. of Functioning, Disability, and Health
from the Orthopedic Section of the Amer-
outcome in patients who receive ican Physical Therapy Association.
DOI: 10.2522/ptj.20140156
matched care (type and intensity J Orthop Sports Phys Ther. 2008;38:A1–
A34.
of the intervention) with those
References 14 Fritz JM, Cleland JA, Childs JD. Subgroup-
receiving nonmatched care. ing patients with low back pain: evolution
1 Luime JJ, Koes BW, Hendriksen IJ, et al. of a classification approach to physical
Prevalence and incidence of shoulder pain therapy. J Orthop Sports Phys Ther. 2007;
5. The actual value (benefit/cost) of in the general population; a systematic 37:290 –302.
utilizing the STAR classification review. Scand J Rheumatol. 2004;33:73–
81. 15 Brennan GP, Fritz JM, Hunter SJ, et al.
approach needs to be evaluated. Identifying subgroups of patients with
This value could be determined 2 Hegedus EJ, Goode AP, Cook CE, et al. acute/subacute “nonspecific” low back
Which physical examination tests provide pain: results of a randomized clinical trial.
by comparing cost of care, includ- clinicians with the most value when exam- Spine (Phila Pa 1976.). 2006;31:623–
ing current and downstream utili- ining the shoulder? Update of a systematic 631.
review with meta-analysis of individual
zation of health care for the con- tests. Br J Sports Med. 2012;46:964 –978. 16 Fritz JM, Brennan GP. Preliminary exami-
nation of a proposed treatment-based clas-
dition initially treated using the 3 Ludewig PM, Lawrence RL, Braman JP. sification system for patients receiving
STAR classification, as well as out- What’s in a name? Using movement system physical therapy interventions for neck
diagnoses versus pathoanatomic diagno- pain. Phys Ther. 2007;87:513–524.
comes in patients who receive ses. J Orthop Sports Phys Ther. 2013;43:
matched care with those receiv- 280 –283. 17 Fritz JM, Cleland JA, Brennan GP. Does
adherence to the guideline recommenda-
ing nonmatched care. 4 Schellingerhout JM, Verhagen AP, Thomas tion for active treatments improve the
S, Koes BW. Lack of uniformity in diagnos- quality of care for patients with acute low
tic labeling of shoulder pain: time for a back pain delivered by physical therapists?
Summary different approach. Man Ther. 2008;13: Med.Care. 2007;45:973–980.
Our goal was to propose a testable 478 – 483.
18 Foster NE, Hill JC, O’Sullivan P, Hancock
classification system that is consis- 5 Miller-Spoto M, Gombatto SP. Diagnostic M. Stratified models of care. Best Pract Res
labels assigned to patients with orthopedic Clin Rheumatol. 2013;27:649 – 661.
tent with existing frameworks and conditions and the influence of the label
current practice while providing a on selection of interventions: a qualitative 19 Foster NE, Mullis R, Hill JC, et al. Effect of
study of orthopaedic clinical specialists. stratified care for low back pain in family
rehabilitation classification to specif- Phys Ther. 2014;94:776 –791. practice (IMPaCT Back): a prospective
ically guide rehabilitation interven- population-based sequential comparison.
6 Kelley MJ, Shaffer MA, Kuhn JE, et al. Ann Fam Med. 2014;12:102–111.
tion. The proposed system is based Shoulder pain and mobility deficits: adhe-
sive capsulitis. J Orthop Sports Phys Ther. 20 Hanchard NC, Cummins J, Jeffries C.
on the belief that the pathoanatomic 2013;43:A1–A31. Evidence-Based Clinical Guidelines for
diagnostic model, although helpful, the Diagnosis, Assessment, and Physio-
7 Ahn KS, Kang CH, Oh YW, Jeong WK. therapy Management of Shoulder
is insufficient for guiding rehabilita- Correlation between magnetic resonance Impingement Syndrome. London, United
tion intervention. The proposed imaging and clinical impairment in Kingdom: Chartered Society of Physiother-
patients with adhesive capsulitis. Skeletal apy; 2004.
model extends the pathoanatomic Radiol. 2012;41:1301–1308.
model by classifying tissue irritability 21 Hanchard NC, Goodchild L, Thompson J,
8 Kim HM, Teefey SA, Zelig A, et al. Shoul- et al. Evidence-based clinical guidelines
and specific impairments. Tissue irri- der strength in asymptomatic individuals for the diagnosis, assessment and physio-
tability is meant to guide intensity of with intact compared with torn rotator therapy management of contracted (fro-
cuffs. J Bone Joint Surg Am. 2009;91:289 – zen) shoulder: quick reference summary.
treatment, and identifying specific 296. Physiotherapy. 2012;98:117–120.

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22 Kromer TO, Tautenhahn UG, de Bie RA, 30 Wainner RS, Fritz JM, Irrgang JJ, et al. Reli- 39 Osteras H, Torstensen TA, Osteras B. High-
et al. Effects of physiotherapy in patients ability and diagnostic accuracy of the clin- dosage medical exercise therapy in
with shoulder impingement syndrome: a ical examination and patient self-report patients with long-term subacromial shoul-
systematic review of the literature. J Reha- measures for cervical radiculopathy. Spine der pain: a randomized controlled trial.
bil Med. 2009;41:870 – 880. (Phila Pa 1976). 2003;28:52– 62. Physiother Res Int. 2010;15:232–242.
23 Pedowitz RA, Yamaguchi K, Ahmad CS, 31 Rubinstein SM, Pool JJ, van Tulder MW, 40 Ginn KA, Cohen ML. Exercise therapy for
et al. Optimizing the management of rota- et al. A systematic review of the diagnostic shoulder pain aimed at restoring neuro-
tor cuff problems. J Am Acad Orthop accuracy of provocative tests of the neck muscular control: a randomized compara-
Surg. 2011;19:368 –379. for diagnosing cervical radiculopathy. Eur tive clinical trial. J Rehabil Med. 2005;37:
Spine J. 2007;16:307–319. 115–122.
24 Yung E, Asavasopon S, Godges JJ. Screen-
ing for head, neck, and shoulder pathol- 32 Tong HC, Haig AJ, Yamakawa K. The
Spurling test and cervical radiculopathy. 41 Ludewig PM, Borstad JD. Effects of a home
ogy in patients with upper extremity signs exercise programme on shoulder pain and
and symptoms. J Hand Ther. 2010;23: Spine (Phila Pa 1976). 2002;27:156 –159.
functional status in construction workers.
173–185; quiz 186. 33 Lahteenmaki HE, Virolainen P, Hiltunen A, Occup Environ Med. 2003;60:841– 849.
25 Mitchell C, Adebajo A, Hay E, Carr A. et al. Results of early operative treatment
Shoulder pain: diagnosis and management of rotator cuff tears with acute symptoms. 42 Senbursa G, Baltaci G, Atay A. Comparison

Downloaded from https://academic.oup.com/ptj/article/95/5/791/2686487 by guest on 31 March 2023

in primary care. BMJ. 2005;331:1124 – J Shoulder Elbow Surg. 2006;15:148 –153. of conservative treatment with and with-
1128. out manual physical therapy for patients
34 Tashjian RZ. Epidemiology, natural his- with shoulder impingement syndrome: a
26 Goodman CC. Screening for medical prob- tory, and indications for treatment of rota- prospective, randomized clinical trial.
lems in patients with upper extremity tor cuff tears. Clin Sports Med. 2012;31: Knee Surg Sports Traumatol Arthrosc.
signs and symptoms. J Hand Ther. 2010; 589 – 604. 2007;15:915–921.
23:105–125; quiz 126. 35 Matsen FA III, Chebli C, Lippitt S. Princi-
ples for the evaluation and management of 43 Tate AR, McClure PW, Young IA, et al.
27 Feleus A, van DT, Bierma-Zeinstra SM, Comprehensive impairment-based exer-
et al. Kinesiophobia in patients with non- shoulder instability. J Bone Joint Surg Am.
2006;88:648 – 659. cise and manual therapy intervention for
traumatic arm, neck and shoulder com- patients with subacromial impingement
plaints: a prospective cohort study in gen- 36 Denard PJ, Wirth MA, Orfaly RM. Manage- syndrome: a case series. J Orthop Sports
eral practice. BMC Musculoskelet Disord. ment of glenohumeral arthritis in the Phys Ther. 2010;40:474 – 493.
2007;8:117. young adult. J Bone Joint Surg Am. 2011;
93:885– 892. 44 Nijs J, Torres-Cueco R, van Wilgen CP,
28 Karels CH, Bierma-Zeinstra SM, Burdorf A, et al. Applying modern pain neuroscience
et al. Social and psychological factors 37 Monk AP, Roberts PG, Logishetty K, et al. in clinical practice: criteria for the classi-
influenced the course of arm, neck and Evidence in managing traumatic anterior fication of central sensitization pain. Pain
shoulder complaints. J Clin Epidemiol. shoulder instability: a scoping review. Br J Physician. 2014;17:447– 457.
2007;60:839 – 848. Sports Med. 2015;49:307–311.
29 Mintken PE, Cleland JA, Whitman JM, 38 Kuhn JE, Dunn WR, Sanders R, et al. Effec- 45 International Classification of Function-
George SZ. Psychometric properties of the tiveness of physical therapy in treating ing, Disability and Health (ICF). Available
Fear-Avoidance Beliefs Questionnaire and atraumatic full-thickness rotator cuff tears: at: http://www.who.int/classifications/
Tampa Scale of Kinesiophobia in patients a multicenter prospective cohort study. J icf/en/.
with shoulder pain. Arch Phys Med Reha- Shoulder Elbow Surg. 2013;22:1371–
bil. 2010;91:1128 –1136. 1379.

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