0:04 This is Brent of the Brookbush Institute, and 0:05 in this video we're going over special 0:07 or orthopedic tests for the shoulder. 0:09 Specifically how do we cluster tests to 0:12 increase the specificity and sensitivity 0:14 of our labral tear assessment. So the 0:18 first problem we have is we have 0:19 multiple research studies from multiple 0:21 researchers, they don't always use the 0:24 same test, nor the same message, nor the 0:27 same analysis. So how do we pick that one 0:30 set, or that one cluster of tests that 0:33 we're going to use in the clinic. I think 0:36 the best thing to do is probably start 0:38 with some trends that we see across all 0:40 of these studies, we can break the tests 0:44 themselves into three groups. There 0:46 seemed to be a correlation between the 0:48 apprehension tests, that would be 0:51 apprehension and Jobe's relocation, and 0:53 labral tears. Kind of makes sense, if I 0:56 tear my labrum I might lose a little 0:58 shoulder stability. The second group of 1:01 tests that are commonly used are the 1:03 Speeds, and O'Brien's active compression 1:06 test. We'll call those our standing 1:08 flexion tests. All right so now we 1:11 have our apprehension and our standing 1:14 flexion test, there's a third group of 1:17 tests used in one specific set of 1:20 research that seems to increase 1:22 specificity, and that's the bicep's load 1:25 2 or the compression rotation test. So 1:29 now how do I choose. Well if we're going 1:33 to just pick one study that actually 1:37 used two good tests, and we're going to 1:41 say good test is based on other research 1:45 that looked at the reliability of one 1:47 specific test at a time, we find that the 1:51 Jobe's relocation and the O'Brien's active 1:55 compression tests are two fairly good 1:58 tests, that when combined increase the 2:02 reliability of our assessment of labral 2:05 tears. So we could just start there, use 2:08 those two tests, but what about this 2:11 third group that increases specificity. 2:13 Well it'd be nice to grab the best of 2:15 those two tests, especially considering 2:17 the compression rotation test is 2:19 actually a pretty bad test when it comes 2:22 to specificity and sensitivity. 2:23 Unfortunately if we add that third test, 2:28 the only study we have that looked at 2:31 adding that those tests added them both, 2:34 right so now we have the Biceps load 2, the 2:40 compression rotation and O'Brien's test 2:43 combined. and that's not exactly how I 2:46 would have created that cluster, right we 2:49 just lost our apprehension test which 2:51 seemed to be correlated with our labral 2:53 tears, and we have to include this one 2:56 test that like I said is not a great 3:00 test, and if I could I would sweep it 3:02 away. So where do we go from here? Well if 3:06 you're me I'm going to take a chance, i'm 3:10 going to use Jobe's relocation and 3:12 O'Brien's active compression which I 3:15 know work well together, and I'm going to 3:17 add biceps load 2 which seems to 3:20 increase specificity, despite the fact 3:23 that i don't have one study on the three 3:26 of those tests combined. So what does 3:29 that look like, I'm going to have my 3:31 friend Melissa come out she's going to 3:33 help me demonstrate. So first things 3:37 first, let's say Melissa came in and she 3:40 complaining about an acute trauma. She 3:43 remembers when she first started 3:45 having that pain, maybe it even started 3:47 with a click or a pop, she happens to be 3:49 an overhead athlete, maybe she's a 3:51 volleyball player right, and this pain 3:54 started about a week, week and a half ago 3:55 and it doesn't seem to want to go away. 3:57 All right I got a good sense that labral 4:00 tear could be a possible diagnosis. I'm 4:04 going to start with my O'Brien test. My 4:06 O'Brien test -I'm going to have Melissa 4:07 go ahead and lift her arm up to 90 4:10 degrees, i'm going to have her turn in 4:11 completely. I'm going to put some 4:14 downward force through her arm, and if 4:16 she complains about pain inside her 4:19 shoulder, 4:22 and then when I do it this way right so 4:25 completely externally rotateD and 4:26 supinated, she says that either feels 4:30 better as in less pain, or there's no 4:32 pain at all that's a positive O'Brien's 4:35 test, I'm now 1 for 3 right. So she has pain 4:39 inside her shoulder, not to be confused 4:42 with pain on top of her shoulder. She 4:43 has pain inside her shoulder when I do 4:45 this, but less pain when I do that. Okay 4:50 that's one positive test. I'm then 4:53 going to ask Melissa to lie 4:55 down. Now I'm going to do Jobe's relocation 4:59 which is a modification on my 5:01 apprehension test. Can you scoot this way 5:02 just a little bit Melissa. If I was doing 5:05 Jobe's relocation this wouldn't feel very 5:08 good, as soon as I got here she'd start 5:11 to guard on me. She might not even have 5:12 pain, she'll just guard, she just doesn't 5:14 want me to let her go back there, but if 5:17 I give her some external stabilization 5:20 of her humeral head, now she'll let me go 5:24 back and she'll even tell me that 5:26 this feels better. Alright so a little 5:30 anterior compression, a little false 5:33 stabilization of her humeral head and 5:35 she's feeling better. If that's the case 5:39 it's a positive Jobe's relocation test. Now 5:42 I have two strikes, and or two points 5:46 towards a diagnosis of labral tear. The 5:50 last one is I'm going to have Melissa 5:52 scoot over just a little bit that way. 5:53 I'm going to make sure that her scapula 5:57 is a neutral position. I'm going to take 5:59 her up to about a hundred and thirty 6:00 degrees of abduction, and then I'm going 6:02 to go -hey slowly can you just kind of flex 6:06 your bicep for me. There you go, and if 6:10 she complained of pain again, this 6:13 replicated her symptoms, I'd be three for 6:17 three that'd be a positive biceps load 6:20 2, and I'd have another piece of 6:26 evidence towards a labral tear. Alright 6:30 so remember what I told you at the 6:33 beginning of this, 6:34 there's a lot of research it doesn't 6:37 necessarily conflict but it doesn't 6:39 exactly match either. If you were going 6:42 to use two tests that are backed by a 6:47 research study, that we do have evidence 6:50 third-party evidence that when the two 6:52 tests are combined we get higher 6:55 specificity and sensitivity, just go with 6:58 O'Brien's and Jobe's relocation. You could 7:01 also go with speeds and apprehension, but 7:04 like i said i think O'Brien's and Jobe's 7:06 relocation are the better of those tests. 7:08 If you add biceps load 2 you might be 7:13 increasing your specificity, but we don't 7:16 have a particular study to pull that all 7:19 together. I hope to see a study like that 7:22 very soon. So just out of total humility 7:27 and knowing that there are other answers 7:30 out there, the Brookbush Institute 7:32 cluster the best thing I can figure out 7:35 based on the research I've seen, would be 7:38 Jobe's relocation along with O'Brien's active 7:42 compression, along with biceps load 7:44 2. I hope you guys enjoyed this video. I 7:46 hope you guys will give these three 7:48 tests some practice. I hope you at least 7:51 start taking steps towards integrating 7:54 testing clusters for all of your various 7:56 pathologies into your clinics. I look 7:59 forward to seeing your questions, and 8:01 we'll talk to you soon. 8:10
