The Health Roundtable

“Burdening the Shoulder? Don’t Shoulder the Burden!”

Presenter: Judy Chen

Hospital Code Name: The Prince of Wales Hospital

Innovation Poster SessionHRT1215 – Innovation AwardsSydney 11th and 12th Oct 2012

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KEY PROBLEM

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AIM OF THIS INNOVATION

Empower patients Self management strategies Avoid protracted course of therapy Improve quality of life Decrease utilisation of health services

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BASELINE DATA High prevalence of ongoing shoulder pain with ageing

population (Chard et al 1991; Chakravarty & Webley 1990; Vecchio et al 1995)

> 30% still has shoulder pain after 2-3 years (Linsell 2006; Winters 1999; Zheng 2005)

POW QA Survey of Referrals for Shoulder Dysfunction:

1993: 10% shoulder referrals

2008: second largest group of all referrals

2009: 50%

C/S

L/S

T/S

Sh

Elbow

Wrist

Hip 0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Cx spine Tx spine Lx / SIJ hip / thigh knee / lowerleg

ankle / foot shoulder /upper arm

elbow /forearm

wrist / hand

Problem area

Occasions of Service per Diagnosis, 2008 C/S 4.5 L/S 5.6 T/S 3.6 Shoulder 6.3 (NSW 9.2) Elbow 5.3 Wrist 2.5 Hip 4.7 Knee 3.5 Ankle 3.8 Foot 4 # Shoulder 4.2 # Ankle 4.2 # Others 5.8 Sx Shoulder 7.9 Sx Ankle 5.4 Sx Others5.8 Deconditioned 0

C/S

T/S

L/S

Hip

Knee

Ankle

Shoulder

Elbow

Wrist/Hand

80% non-shoulder problems improved to 80-90%

All shoulder patients : 30 – 50%19.6 “frequent flyers”

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KEY CHANGES IMPLEMENTED

Chronic care model: 8 week twice weekly group programInclusion criteria: One-on-one treatment Chronic shoulder pain- after 4 sessions Exhausted allocated sessions Achieved maximum benefit after 1-1, need further

education/ exercise to prevent recurrenceEducation (goal setting, shoulder anatomy, treatment

options, shoulder specific/general exercise, joint care, healthy living etc)

Exercise (neuromuscular control exercises, general fitness exercises)

Use existing staff, cost-neutral(Plan: RCT for patients on waiting list for shoulder surgery)

OUTCOMES SO FAR

NO RE-REFERERALSNo “Frequent flyers” re-

presenting

Fig 1 Improvement (higher score) in lifting ability over time.

Fig 2 Measurement of active shoulder range of motion- flexion and hand-behind-back (HBB) reach. A high score in flexion indicates improvement whereas a decrease in HBB indicates improvement .

Fig 3 Physical function tests- 6 minute walk test (distance walked in 6 minutes -in metres), and stair climbing (steps climbed in 2 minutes).

Fig 4 Outcome of SF36 quality of life questionnaire- both physical component score (PCS) and mental component score (MCS) demonstrates improvement in all domains of physical and mental function.

Fig 5 Patient self-perceived improvement in pain measured on an 11-point visual analogue scale. 0 = no pain; 10 = the worst pain imaginable.

LESSONS LEARNT

Great for team building

Worthwhile problem-solving process

Recruitment of participants

Upskill staff in program delivery & exercise prescription

Refine recruitment process (information brochure, explanation to patient)

Consider entry to Exercise program while waiting for commencement of educational program

Involve all staff to ensure continuity