1. The Health Roundtable “Burdening the Shoulder? Don’t Shoulder the Burden!” Presenter: Judy Chen Hospital Code Name: The Prince of Wales Hospital Innovation Poster Session HRT1215 – Innovation Awards Sydney 11 th and 12 th Oct 2012

2. The Health Roundtable KEY PROBLEM ↑ referrals for ongoing shoulder dysfunction ↑ waiting list → restriction of 1-1 sessions Patients discharged with limited improvement Re-referred for further 1-1 treatment Staff frustration ↑↑ waiting list

3. The Health Roundtable AIM OF THIS INNOVATION  Empower patients  Self management strategies  Avoid protracted course of therapy  Improve quality of life  Decrease utilisation of health services

4. The Health Roundtable 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%

5. Occasions of Service per Diagnosis, 2008  C/S4.5  L/S5.6  T/S3.6  Shoulder6.3 (NSW 9.2)  Elbow5.3  Wrist2.5  Hip4.7  Knee3.5  Ankle3.8  Foot4  # Shoulder4.2  # Ankle4.2  # Others5.8  Sx Shoulder7.9  Sx Ankle5.4  Sx Others5.8  Deconditioned0 80% non-shoulder problems improved to 80-90% All shoulder patients : 30 – 50% 19.6 “frequent flyers”

6. The Health Roundtable KEY CHANGES IMPLEMENTED Chronic care model: 8 week twice weekly group program Inclusion 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 recurrence Education (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)

7. OUTCOMES SO FAR NO RE-REFERERALS No “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.

8. 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