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