Advances in Rehabilitation of the Shoulder

Photo: Jo GibsonJo Gibson is a Clinical Physiotherapy Specialist at the Liverpool Upper Limb Unit based at the Royal Liverpool Hospital, UK. She lectures both nationally and internationally about rehabilitation of the shoulder. Her research interests are shoulder instability and motor learning. Jo is currently Squad Physiotherapist for the Great Britain Endurance riding Team. She is the co-author of the GOST booklet, a Guide for Orthopaedic Surgeons and Therapists regarding operative and postoperative management of Upper Limb Patients.

Jo is an expert in shoulder rehabilitation and she recently took time out to discuss the latest advances in this rapidly developing specialty.

Conventionally, all first time shoulder dislocations are immobilised in a sling with the arm across the body. Is this always the best position of immobilisation?

"Imaging techniques such as MRI (magnetic resonance imaging), together with advances in arthroscopy, have enabled improved visualisation of the glenohumeral (shoulder) joint structures. This has led to authors challenging the conventional cross-arm sling position of immobilisation. Eiji Itoi's work concluded that, in the case of a first time dislocator with a classic Bankart lesion, it may be more appropriate to immobilise patients in an external rotation brace (with the shoulder turned out as opposed to the conventional 'sling' position, where it is turned in across the body). He demonstrated that the external rotation position resulted in better coaptation of the capsular-labral lesion to the glenoid and resulted in good healing and low recurrence rates long term.

"However, it is important to recognise that Itoi's work involved only 16 patients in the final analysis and patient selection was an important feature of successful management. It is also important to note that management of the first time dislocator varies amongst shoulder surgeons. In the UK, Shoulder surgeons who use arthroscopy rather than open surgery as their treatment of choice are more likely to repair a young sports-person with a first time dislocation, rather than immobilise the shoulder.

"Handell et al support the UK approach in their Cochrane systematic review of the available scientific research. They concluded that 'the limited evidence available supports primary surgery for young adults, usually male, engaged in highly demanding physical activities who have sustained their first acute traumatic shoulder dislocation. There is no evidence available to determine whether non-surgical treatment should not remain the prime treatment option for other, less active categories of patient.' There is immense interest in Itoi's work and I suspect there will be a glut of papers investigating the use of the external rotation position in both the low and high-risk patients in the near future."

[1]

Recent research has indicated that accelerated rehabilitation under the supervision of a chartered physiotherapist may be helpful in improving patients' outcome. What are the main differences between the accelerated approach and the more conventional approach to rehab?

"In conventional rehabilitation the patient is immobilised in a sling for a period of up to 3 weeks, depending on whether the surgery is performed arthroscopically (3 weeks) or Open (2 weeks). They are usually only allowed to do gentle isometric exercises (muscle contractions without joint movement) for the rotator cuff and scapula muscles during this period.

"In the accelerated approach patients are allowed to start active mobilisation in a protected arc of movement within 48 hours of surgery. The arc is identified by the surgeon's operative findings to establish in what positions tension is created across the surgical repair. This highlights the importance of communication between physiotherapist and surgeon to optimise patient outcomes. Due to the early commencement of mobilisation, the patient is able to do more specific stability work including closed kinetic chain exercises (where the hand is fixed to an object that is either stationary or moving) in more functional positions very early in the rehabilitation process.

"Seung-Ho Kim et al compared the results of accelerated rehabilitation versus conventional mobilisation in patients undergoing arthroscopic Bankart repair. Patients undergoing accelerated rehabilitation resumed functional movement faster and returned earlier to their functional level of activity. This group also demonstrated decreased postoperative pain and patient satisfaction was higher. There was no significant difference in recurrence rates at a mean follow-up of 31 months. However, patient selection is a very important factor in ensuring success with the accelerated approach."

[2]

You identify three distinct phases following shoulder instability surgery: the Protective phase, the Intermediate phase and the Late phase. Could you briefly outline the typical goals of physiotherapy treatment during each phase?

"The initial protective phase essentially addresses restrictions imposed by the surgical procedure and aims to minimise the effects of any immobilisation period. Goals are to diminish pain and swelling, maintain passive range of motion (within surgical limits), improve proprioception and optimise muscle recruitment with specific emphasis on the dynamic stabilisers (muscles which control the humeral head and shoulder blade). It is essential in avoiding compromise of the surgical procedure to consider the 'normal' healing response and identify factors that may affect it.

"The Intermediate phase aims to restore full active range of movement and dynamic stability through the full range of movement. There may be some continued restrictions on combined positions e.g. abduction/external rotation following Bankart/SLAP repair. This phase includes further emphasis on proprioception and specific neuromuscular control strategies.

"The final late phase emphasises dynamic stability throughout all active ranges of movement, with specific attention to more reactive stabilisation control and strength/endurance relevant to the patient's functional activity/sport."

Could you briefly explain 'muscle patterning' in the shoulder and the effect it can have on rehabilitation outcomes?

"Muscle Patterning refers to inappropriate recruitment, commonly of the torque producing muscles of the glenohumeral joint e.g. Latissimus Dorsi, Pectoralis Major, Anterior /Posterior Deltoid, resulting in uncontrolled translation of the humeral head and often subluxation or dislocation of the glenohumeral joint. This unbalanced muscle action is involuntary and ingrained. Patients with muscle patterning essentially have a muscle recruitment sequencing problem that results in abnormal force couples destabilising the joint.

"Unfortunately, it is often missed in patients with instability and is a common factor in patients failing conventional rehabilitation programmes and/or surgery. This is not a strength problem but a sequencing problem. Patients who are given more traditional strength exercises such as cuff strengthening with elastic tubing will complain of an exacerbation of pain and instability as they 'fix' against the resistance of the tubing and reinforce the Muscle Patterning component. This prevents effective recruitment of the cuff muscles.

"The 'Stanmore triangle' (a classification system for patients with shoulder instability) has helped to recognise the importance of identifying those patients with instability with a structural component that will benefit from surgery and those that should primarily be a conservative rehabilitation candidate. Muscle Patterning should generally be considered as a contra-indication for surgery - the force of contraction is often sufficient to sublux or dislocate the joint and so will potentially compromise the surgical repair. Working in a tertiary referral unit we unfortunately see the consequences of repeated attempts to surgically stabilise a shoulder with Muscle patterning with the pain and disability that ensues. Identification of this patient group is paramount to ensure appropriate rehabilitation is implemented.

"Rehabilitation is aimed at 'normalising' muscle recruitment patterns around the shoulder girdle and this involves appropriate facilitation throughout the kinetic chain. Balance, coordination and core control are all factors that must be addressed with this patient group to optimise neuromuscular control mechanisms."

[3]

Why is Scapula control so important in patients with shoulder instability?

"Optimal scapula mechanics function to provide a stable glenoid to serve as a secure platform for the humeral head. The glenohumeral joint is an inherently unstable joint due to the mismatch between the large humeral head and small glenoid. It is therefore very dependent on the muscles and capsulo-ligamentous structures for its stability. Optimal muscle control results in maximal congruency of the bony structures.

"Scapula dyskinesis (abnormal scapula movement) is a common feature of shoulder instability. Serratus Anterior and upper and lower Trapezius muscles are the principle upward rotators of the scapula. Common patterns of scapula dyskinesia in patients with instability are the loss of normal protraction and posterior tilt. In simple terms, this can have the result that the glenoid (the shoulder socket, part of the shoulder blade) does not 'keep up' with the humeral head (Ball of the shoulder joint), therefore the joint congruency is lost. Furthermore this compromises the optimal length-tension relationships of the scapula-humeral musculature - so decreasing the dynamic stability function of these muscles.

"Essentially the humeral head is then dependent on the soft tissue structures for stability. This can potentially result in pain and instability. In both conservatively managed patients, and those post surgery, it is essential to rehabilitate optimal scapula mechanics to ensure optimal congruency of the bony structures and optimal recruitment of the scapulo-humeral muscles."

[4][5]

References >

Contact Jo Gibson >





Row View Grid View

Ultimate Performance Neoprene Shoulder Support

£29.99 inc VAT

A combination of theraputic heat and support promotes improved healing after shoulder injury and complaints such as arthritis and rotator cuff tendonitis.
More Details

Ultimate Performance Neoprene Shoulder Support has a rating of 5.0 stars from 4 reviews (4 reviews)

Availability: Selected options in stock

Quantity

Donjoy Sully Shoulder

£99.99 inc VAT

The Donjoy Sully Shoulder support is a highly functional product designed to follow the natural motion of the shoulder muscles and joint. Offering controlled assistance the Sully will stabilise and/or restrict movement following dislocation or subluxation according to your specific needs.
More Details

Availability: In Stock

Quantity

Aircast Arm Immobiliser

£29.99 inc VAT

The Aircast Arm Immobiliser provides a protective and secure support for a number of arm and shoulder injuries. Featuring innovative tri-strap fixing, the adjustable fastening can be altered to provide a truly tailored fit for enhanced comfort and protection.
More Details

Availability: Selected options in stock

Quantity

ProCare Immo Sling & Swathe

£24.99 inc VAT

The ProCare Immo Sling and Swathe is a lightweight support designed to immobilise the upper extremity after trauma. Featuring a terrycloth lined cradle and straps for added comfort the brace comes with an additional adjustable belt which can be used to fix the arm.
More Details

Availability: Selected options in stock

Quantity

Mueller Shoulder Support

£69.99 inc VAT


More Details

Availability: In Stock

Quantity

medi Omomed Shoulder Brace

£79.99 inc VAT


More Details

Availability: In Stock

Quantity

Ultimate Performance Advanced Shoulder Support

£39.99 inc VAT


More Details

Availability: In Stock

Quantity

PhysioRoom.com Arm and Shoulder Sling

7.50 inc VAT Was 12.50 Save 5.00 (40%)

Arm and Shoulder Sling that features comfortable straps and is designed for use following shoulder injuries and shoulder surgery.
More Details

PhysioRoom.com Arm and Shoulder Sling has a rating of 5.0 stars from 2 reviews (2 reviews)

Availability: In Stock

Quantity

Bauerfeind OmoTrain Shoulder Support

£96.99 inc VAT

Active shoulder support that provides functional treatment and pain relief following shoulder injuries.
More Details

Availability: Delivered within 3 to 5 working days

Quantity

PhysioRoom.com Shoulder Support Strap

17.99 inc VAT Was 24.99 Save 7.00 (28%)

High quality custom fit shoulder strap to aid injuries such as bursitis, myositis and tendonitis.
More Details

PhysioRoom.com Shoulder Support Strap has a rating of 5.0 stars from 17 reviews (17 reviews)

Availability: In Stock

Quantity

PhysioRoom.com Deluxe Elite Arm Sling

4.95 inc VAT Was 11.95 Save 7.00 (59%)

The deluxe elite arm sling has been specially designed for use following a shoulder injury or shoulder surgery and features a foam pad to ensure of total comfort.
More Details

PhysioRoom.com Deluxe Elite Arm Sling has a rating of 4.5 stars from 3 reviews (3 reviews)

Availability: In Stock

Quantity

PhysioRoom.com Sprains & Strains Repair Kit

12.15 inc VAT Was 16.99 Save 4.84 (28%)

Essential ice and compression kit to relieve pain, reduce swelling and speed up recovery following a sports injury, muscle strain or ligament sprain.
More Details

PhysioRoom.com Sprains & Strains Repair Kit has a rating of 5.0 stars from 1 reviews (1 review)

Availability: In Stock

Quantity

Physicool Cooling Bandage (10cm x 2m) - Ideal for wrists, ankles, elbows

£9.99 inc VAT

Physicool is an innovative and uniquely designed reusable strapping that combines the healing characteristics of cold therapy with the support qualities of a compression bandage. Differing from the more traditional treatments currently available, Physicool works by drawing heat away from the body to provide an instant long-lasting cooling effect which can be utilised for extended periods.
More Details

Physicool Cooling Bandage (10cm x 2m) - Ideal for wrists, ankles, elbows has a rating of 5.0 stars from 2 reviews (2 reviews)

Availability: In Stock

Quantity

Physicool Cooling Bandage (12cm x 3m) - Ideal for knees, legs, shoulders, back

£12.99 inc VAT

Physicool is a new and unique way to instantly apply cold therapy whilst on the move, this portable and reusable compression bandage is applied quickly and easily allowing the healing process to begin immediately. By taking heat away from the body Pysicool have developed a product which differs from move traditional methods meaning it can be used for longer periods.
More Details

Physicool Cooling Bandage (12cm x 3m) - Ideal for knees, legs, shoulders, back has a rating of 5.0 stars from 3 reviews (3 reviews)

Availability: In Stock

Quantity

Hyperice Shoulder Support

£74.99 inc VAT

The Hyperice cold therapy system is an innovative application device created to ensure optimal ice treatment on the move, sub-zero compression without limitation.
More Details

Availability: In Stock

Quantity

Hyperice Extended Shoulder

89.99 inc VAT Was 99.99 Save 10.00 (10%)

The Hyperice cold therapy system is an innovative application device created to ensure optimal ice treatment on the move, sub-zero compression without limitation.
More Details

Availability: In Stock

Quantity

Mentholatum Deep Relief Gel

6.99 inc VAT Was 7.99 Save 1.00 (13%)

Deep Relief dual action gel with ibuprofen is a clear, non-sticky and non-greasy gel with a mild, pleasant menthol fragrance.
More Details

Mentholatum Deep Relief Gel has a rating of 5.0 stars from 2 reviews (2 reviews)

Availability: In Stock

Quantity

PhysioRoom.com Resistance Exercise Band

2.49 inc VAT Was 5.49 Save 3.00 (55%)

Latex Bands provide light, medium to heavy resistance during training exercises and are designed for increasing strengthening exercises during rehab and sports training. 99.99% free from latex allergens.
More Details

PhysioRoom.com Resistance Exercise Band has a rating of 5.0 stars from 1 reviews (1 review)

Availability: In Stock

Quantity

PhysioRoom.com Resistance Band Exercise Loop

1.49 inc VAT Was 2.49 Save 1.00 (40%)

These multi-coloured tubes provide four levels of resistance, ideal for progressing strengthening exercises.
More Details

PhysioRoom.com Resistance Band Exercise Loop has a rating of 5.0 stars from 3 reviews (3 reviews)

Availability: In Stock

Quantity

PhysioRoom.com Hand Grip Exerciser

1.49 inc VAT Was 6.99 Save 5.50 (79%)

Durable handles and resistance springs demonstrates the high quality of the Hand Grip Exerciser by PhysioRoom.com. Use it to strengthen muscles in the hands, arms and wrists.
More Details

PhysioRoom.com Hand Grip Exerciser has a rating of 5.0 stars from 1 reviews (1 review)

Availability: In Stock

Quantity

PhysioRoom.com Exercise Band Loop (medium) - Pack of 5

6.99 inc VAT Was 14.99 Save 8.00 (53%)

These red coloured tubes provide medium resistance, ideal for progressing strengthening exercises.
More Details

PhysioRoom.com Exercise Band Loop (medium) - Pack of 5 has a rating of 5.0 stars from 1 reviews (1 review)

Availability: In Stock

Quantity

PhysioRoom.com The PhysioRoom Rehab and Fitness Exercise Pack

£37.99 inc VAT

The ultimate rehab and fitness kit, also perfect for Yoga and Pilates. Everything you will need for excerise or rehab following a sporting injury, for use at home.
More Details

Availability: In Stock

Quantity

PhysioRoom.com 5.5m x15cm Resistance Band Box - Choose between 5 Levels

7.99 inc VAT Was 14.99 Save 7.00 (47%)

Latex Bands provide light, medium to heavy resistance during training exercises and are designed for increasing strengthening exercises during rehab and sports training.
More Details

PhysioRoom.com 5.5m x15cm Resistance Band Box - Choose between 5 Levels has a rating of 5.0 stars from 7 reviews (7 reviews)

Availability: In Stock

Quantity

PhysioRoom.com Plastic Speed Skipping Rope With Foam Handles

2.99 inc VAT Was 9.99 Save 7.00 (70%)

The speed skipping rope features ergonomically shaped foam handles which provide a very comfortable grip while skipping.
More Details

Availability: In Stock

Quantity

PhysioRoom.com Hand Grip Strengthener With Foam Handle

2.49 inc VAT Was 4.99 Save 2.50 (50%)

The hand grip strengthener features a foam handle to ensure of a comfortable grip. The hand grip strengthener has durable foam handles and resistance springs to increase the strength of the forearm and the hand grip.
More Details

Availability: In Stock

Quantity

PhysioRoom.com 5.5mx15cm Resistance Bands All Strengths 5 Boxes 5 Levels Of Resistance

39.99 inc VAT Was 59.99 Save 20.00 (33%)

This resistance exercise band pack features five boxes each of which has varying levels of resistance. Each latex band measures 5.5mx15cm and can be cut accordingly to suit your preference. Latex bands provide light, medium to heavy resistance during exercise and are specifically designed to increase strength during rehab and sports training.
More Details

PhysioRoom.com 5.5mx15cm Resistance Bands All Strengths 5 Boxes 5 Levels Of Resistance has a rating of 5.0 stars from 1 reviews (1 review)

Availability: In Stock

Quantity

PhysioRoom.com x2 Hand Grips With Foam Handles

£5.49 inc VAT

The x2 hand grips with foam handles ensure of a totally comfortable grip. The hand grips with foam handles feature resistance springs which help to increase the strength of the forearm and hand grip.
More Details

Availability: In Stock

Quantity

Fitness Mad Studio Pro Adjustable Power Grip

£9.99 inc VAT


More Details

Availability: In Stock

Quantity

Tenscare Touch TENS Machine

30.99 inc VAT Was 41.99 Save 11.00 (26%)

Easy to use dual channel digital TENS machine for effective pain relief featuring seven preset programmes. Just stick on the electrodes, press a button and this simple-to-use TENS machine will use an electrical current to reduce your pain.
More Details

Tenscare Touch TENS Machine has a rating of 5.0 stars from 6 reviews (6 reviews)

Availability: In Stock

Quantity

Tenscare Sports TENS 2

£79.99 inc VAT

Extremely safe and easy-to-use, the TensCare Sport TENS 2 machine has a number of practical functions.
More Details

Tenscare Sports TENS 2 has a rating of 5.0 stars from 1 reviews (1 review)

Availability: In Stock

Quantity

Aircast Shoulder Cryo/Cuff with Cooler

118.86 inc VAT Was 157.99 Save 39.13 (25%)

The ultimate shoulder ice therapy. Provides 6 hours continuous cold and compression to minimise bleeding, swelling and pain.
More Details

Aircast Shoulder Cryo/Cuff with Cooler has a rating of 5.0 stars from 2 reviews (2 reviews)

Availability: In Stock

Shoulder Cryo/Cuff Quantity

Mueller Shape Aerobics Cords

16.99 inc VAT Was 21.99 Save 5.00 (23%)

Light and medium resistance cords with rotator handles with foam grips for rehab and training exercises. For specific strengthening of muscle groups (biceps, triceps etc) and tendons during rehab and sports training.
More Details

Availability: Selected options in stock

Quantity

ProCare Shoulder Sling (with foam straps)

16.99 inc VAT Was 21.99 Save 5.00 (23%)

A shoulder sling with comfortable foam straps for use following shoulder injuries and shoulder surgery.
More Details

ProCare Shoulder Sling (with foam straps) has a rating of 5.0 stars from 5 reviews (5 reviews)

Availability: In Stock

Quantity

PhysioRoom.com Instant Ice Pack

From £0.49 inc VAT     1+ £2.03 each
    6+ £1.49 each (Save 27%)
  12+ £0.99 each (Save 51%)
  24+ £0.69 each (Save 66%)
  50+ £0.49 each (Save 76%)

A mouldable pack that becomes an instant, single use ice pack, without the need for refrigeration.
More Details

PhysioRoom.com Instant Ice Pack has a rating of 5.0 stars from 6 reviews (6 reviews)

Availability: In Stock

Quantity

Vulkan Double Shoulder Support

58.99 inc VAT Was 63.99 Save 5.00 (8%)

Used for dislocated shoulder, frozen shoulder, broken collar bone, Rotator Cuff and Acromio- Clavicular injuries. Provides support, therapeutic heat and shoulder pain relief.
More Details

Vulkan Double Shoulder Support has a rating of 5.0 stars from 2 reviews (2 reviews)

Availability: In Stock

Quantity

Donjoy ArcticFlow Shoulder Wrap with Cooler

101.54 inc VAT Was 125.99 Save 24.45 (19%)

Fantastic value for money continuous ice therapy and compression device for the shoulder.
More Details

Availability: In Stock

Quantity

Donjoy Shoulder Stabiliser

129.99 inc VAT Was 149.99 Save 20.00 (13%)

The best shoulder brace available. Provides maximum protection to prevent a dislocated shoulder; shoulder subluxation; AC joint sprain or rotator cuff tear during sports. Used by pro athletes including the US Skiing team.
More Details

Donjoy Shoulder Stabiliser has a rating of 5.0 stars from 3 reviews (3 reviews)

Availability: In Stock

Quantity

Vulkan Shoulder Strap

£31.99 inc VAT

This high quality neoprene shoulder strap helps reduce shoulder pain, reduce swelling and accelerate healing. Custom fits the shoulder itself.
More Details

Vulkan Shoulder Strap has a rating of 4.5 stars from 6 reviews (6 reviews)

Availability: In Stock

Quantity

Vulkan Left Shoulder Support

43.99 inc VAT Was 53.99 Save 10.00 (19%)

Used for dislocated shoulder, frozen shoulder, broken collar bone, Rotator Cuff and Acromio- Clavicular injuries. Provides support, therapeutic heat and shoulder pain relief. For the right shoulder, please see our product guide for the Vulkan Right Shoulder Support.
More Details

Vulkan Left Shoulder Support has a rating of 4.0 stars from 1 reviews (1 review)

Availability: Selected options in stock

Quantity

Donjoy Ultra Sling II

62.49 inc VAT Was 73.99 Save 11.50 (16%)

A high quality shoulder sling with breathable padded fabric, positioning system and exercise ball to promote shoulder healing.
More Details

Donjoy Ultra Sling II has a rating of 5.0 stars from 1 reviews (1 review)

Availability: In Stock

Quantity

McDavid Universal Shoulder Support

69.95 inc VAT Was 79.95 Save 10.00 (13%)

Reversible and adjustable neoprene shoulder support with a pocket for inserting a hot/cold pack. Perfect for sports use and treatment of all shoulder injuries including a broken Collar bone or dislocated shoulder; Frozen Shoulder and Rotator Cuff injuries.
More Details

McDavid Universal Shoulder Support has a rating of 4.5 stars from 2 reviews (2 reviews)

Availability: In Stock

Quantity

Vulkan Right Shoulder Support

45.67 inc VAT Was 53.99 Save 8.32 (15%)

Used for dislocated shoulder, frozen shoulder, broken collar bone, Rotator Cuff and Acromio- Clavicular injuries. Provides support, therapeutic heat and shoulder pain relief. For the left shoulder, please see our product guide for the Vulkan Left Shoulder Support.
More Details

Vulkan Right Shoulder Support has a rating of 4.0 stars from 1 reviews (1 review)

Availability: In Stock

Quantity

Row View Grid View




Related Articles