00:04 - 00:05This is Brent of the Brookbush Institute, and
00:05 - 00:07in this video we're going over special
00:07 - 00:09or orthopedic tests for the shoulder.
00:09 - 00:12Specifically how do we cluster tests to
00:12 - 00:14increase the specificity and sensitivity
00:14 - 00:18of our labral tear assessment. So the
00:18 - 00:19first problem we have is we have
00:19 - 00:21multiple research studies from multiple
00:21 - 00:24researchers, they don't always use the
00:24 - 00:27same test, nor the same message, nor the
00:27 - 00:30same analysis. So how do we pick that one
00:30 - 00:33set, or that one cluster of tests that
00:33 - 00:36we're going to use in the clinic. I think
00:36 - 00:38the best thing to do is probably start
00:38 - 00:40with some trends that we see across all
00:40 - 00:44of these studies, we can break the tests
00:44 - 00:46themselves into three groups. There
00:46 - 00:48seemed to be a correlation between the
00:48 - 00:51apprehension tests, that would be
00:51 - 00:53apprehension and Jobe's relocation, and
00:53 - 00:56labral tears. Kind of makes sense, if I
00:56 - 00:58tear my labrum I might lose a little
00:58 - 01:01shoulder stability. The second group of
01:01 - 01:03tests that are commonly used are the
01:03 - 01:06Speeds, and O'Brien's active compression
01:06 - 01:08test. We'll call those our standing
01:08 - 01:11flexion tests. All right so now we
01:11 - 01:14have our apprehension and our standing
01:14 - 01:17flexion test, there's a third group of
01:17 - 01:20tests used in one specific set of
01:20 - 01:22research that seems to increase
01:22 - 01:25specificity, and that's the bicep's load
01:25 - 01:292 or the compression rotation test. So
01:29 - 01:33now how do I choose. Well if we're going
01:33 - 01:37to just pick one study that actually
01:37 - 01:41used two good tests, and we're going to
01:41 - 01:45say good test is based on other research
01:45 - 01:47that looked at the reliability of one
01:47 - 01:51specific test at a time, we find that the
01:51 - 01:55Jobe's relocation and the O'Brien's active
01:55 - 01:58compression tests are two fairly good
01:58 - 02:02tests, that when combined increase the
02:02 - 02:05reliability of our assessment of labral
02:05 - 02:08tears. So we could just start there, use
02:08 - 02:11those two tests, but what about this
02:11 - 02:13third group that increases specificity.
02:13 - 02:15Well it'd be nice to grab the best of
02:15 - 02:17those two tests, especially considering
02:17 - 02:19the compression rotation test is
02:19 - 02:22actually a pretty bad test when it comes
02:22 - 02:23to specificity and sensitivity.
02:23 - 02:28Unfortunately if we add that third test,
02:28 - 02:31the only study we have that looked at
02:31 - 02:34adding that those tests added them both,
02:34 - 02:40right so now we have the Biceps load 2, the
02:40 - 02:43compression rotation and O'Brien's test
02:43 - 02:46combined. and that's not exactly how I
02:46 - 02:49would have created that cluster, right we
02:49 - 02:51just lost our apprehension test which
02:51 - 02:53seemed to be correlated with our labral
02:53 - 02:56tears, and we have to include this one
02:56 - 03:00test that like I said is not a great
03:00 - 03:02test, and if I could I would sweep it
03:02 - 03:06away. So where do we go from here? Well if
03:06 - 03:10you're me I'm going to take a chance, i'm
03:10 - 03:12going to use Jobe's relocation and
03:12 - 03:15O'Brien's active compression which I
03:15 - 03:17know work well together, and I'm going to
03:17 - 03:20add biceps load 2 which seems to
03:20 - 03:23increase specificity, despite the fact
03:23 - 03:26that i don't have one study on the three
03:26 - 03:29of those tests combined. So what does
03:29 - 03:31that look like, I'm going to have my
03:31 - 03:33friend Melissa come out she's going to
03:33 - 03:37help me demonstrate. So first things
03:37 - 03:40first, let's say Melissa came in and she
03:40 - 03:43complaining about an acute trauma. She
03:43 - 03:45remembers when she first started
03:45 - 03:47having that pain, maybe it even started
03:47 - 03:49with a click or a pop, she happens to be
03:49 - 03:51an overhead athlete, maybe she's a
03:51 - 03:54volleyball player right, and this pain
03:54 - 03:55started about a week, week and a half ago
03:55 - 03:57and it doesn't seem to want to go away.
03:57 - 04:00All right I got a good sense that labral
04:00 - 04:04tear could be a possible diagnosis. I'm
04:04 - 04:06going to start with my O'Brien test. My
04:06 - 04:07O'Brien test -I'm going to have Melissa
04:07 - 04:10go ahead and lift her arm up to 90
04:10 - 04:11degrees, i'm going to have her turn in
04:11 - 04:14completely. I'm going to put some
04:14 - 04:16downward force through her arm, and if
04:16 - 04:19she complains about pain inside her
04:19 - 04:22shoulder,
04:22 - 04:25and then when I do it this way right so
04:25 - 04:26completely externally rotateD and
04:26 - 04:30supinated, she says that either feels
04:30 - 04:32better as in less pain, or there's no
04:32 - 04:35pain at all that's a positive O'Brien's
04:35 - 04:39test, I'm now 1 for 3 right. So she has pain
04:39 - 04:42inside her shoulder, not to be confused
04:42 - 04:43with pain on top of her shoulder. She
04:43 - 04:45has pain inside her shoulder when I do
04:45 - 04:50this, but less pain when I do that. Okay
04:50 - 04:53that's one positive test. I'm then
04:53 - 04:55going to ask Melissa to lie
04:55 - 04:59down. Now I'm going to do Jobe's relocation
04:59 - 05:01which is a modification on my
05:01 - 05:02apprehension test. Can you scoot this way
05:02 - 05:05just a little bit Melissa. If I was doing
05:05 - 05:08Jobe's relocation this wouldn't feel very
05:08 - 05:11good, as soon as I got here she'd start
05:11 - 05:12to guard on me. She might not even have
05:12 - 05:14pain, she'll just guard, she just doesn't
05:14 - 05:17want me to let her go back there, but if
05:17 - 05:20I give her some external stabilization
05:20 - 05:24of her humeral head, now she'll let me go
05:24 - 05:26back and she'll even tell me that
05:26 - 05:30this feels better. Alright so a little
05:30 - 05:33anterior compression, a little false
05:33 - 05:35stabilization of her humeral head and
05:35 - 05:39she's feeling better. If that's the case
05:39 - 05:42it's a positive Jobe's relocation test. Now
05:42 - 05:46I have two strikes, and or two points
05:46 - 05:50towards a diagnosis of labral tear. The
05:50 - 05:52last one is I'm going to have Melissa
05:52 - 05:53scoot over just a little bit that way.
05:53 - 05:57I'm going to make sure that her scapula
05:57 - 05:59is a neutral position. I'm going to take
05:59 - 06:00her up to about a hundred and thirty
06:00 - 06:02degrees of abduction, and then I'm going
06:02 - 06:06to go -hey slowly can you just kind of flex
06:06 - 06:10your bicep for me. There you go, and if
06:10 - 06:13she complained of pain again, this
06:13 - 06:17replicated her symptoms, I'd be three for
06:17 - 06:20three that'd be a positive biceps load
06:20 - 06:262, and I'd have another piece of
06:26 - 06:30evidence towards a labral tear. Alright
06:30 - 06:33so remember what I told you at the
06:33 - 06:34beginning of this,
06:34 - 06:37there's a lot of research it doesn't
06:37 - 06:39necessarily conflict but it doesn't
06:39 - 06:42exactly match either. If you were going
06:42 - 06:47to use two tests that are backed by a
06:47 - 06:50research study, that we do have evidence
06:50 - 06:52third-party evidence that when the two
06:52 - 06:55tests are combined we get higher
06:55 - 06:58specificity and sensitivity, just go with
06:58 - 07:01O'Brien's and Jobe's relocation. You could
07:01 - 07:04also go with speeds and apprehension, but
07:04 - 07:06like i said i think O'Brien's and Jobe's
07:06 - 07:08relocation are the better of those tests.
07:08 - 07:13If you add biceps load 2 you might be
07:13 - 07:16increasing your specificity, but we don't
07:16 - 07:19have a particular study to pull that all
07:19 - 07:22together. I hope to see a study like that
07:22 - 07:27very soon. So just out of total humility
07:27 - 07:30and knowing that there are other answers
07:30 - 07:32out there, the Brookbush Institute
07:32 - 07:35cluster the best thing I can figure out
07:35 - 07:38based on the research I've seen, would be
07:38 - 07:42Jobe's relocation along with O'Brien's active
07:42 - 07:44compression, along with biceps load
07:44 - 07:462. I hope you guys enjoyed this video. I
07:46 - 07:48hope you guys will give these three
07:48 - 07:51tests some practice. I hope you at least
07:51 - 07:54start taking steps towards integrating
07:54 - 07:56testing clusters for all of your various
07:56 - 07:59pathologies into your clinics. I look
07:59 - 08:01forward to seeing your questions, and
08:01 - 08:04we'll talk to you soon.
08:10 - 08:12