Jo 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."
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."
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."
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."