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Advances in Rehabilitation of the Shoulder

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 motorlearning. 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 andTherapists regarding operative and postoperative management of Upper Limb Patients.

The GOST booklet can be found at www.theupperlimb.com >

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) jointstructures. 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 witha 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 glenoidand 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 thefinal 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 amongstshoulder 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 witha 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 supportsprimary 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 theprime 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 ofthe 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 themain 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 thisperiod.

"In the accelerated approach patients are allowed to start active mobilisation in aprotected arc of movement within 48 hours of surgery. The arc is identified by the

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surgeon's operative findings to establish in what positions tension is created across the

surgical repair. This highlights the importance of communication between physiotherapistand surgeon to optimise patient outcomes. Due to the early commencement of

mobilisation, the patient is able to do more specific stability work including closed kineticchain 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. Patientsundergoing accelerated rehabilitation resumed functional movement faster and returned

earlier to their functional level of activity. This group also demonstrated decreasedpostoperative 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 avery 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 typicalgoals of physiotherapy treatment during each phase?

"The initial protective phase essentially addresses restrictions imposed by the surgicalprocedure 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 isessential 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 dynamicstability 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 neuromuscularcontrol strategies.

"The final late phase emphasises dynamic stability throughout all active ranges ofmovement, 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 musclerecruitment 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 inpatients failing conventional rehabilitation programmes and/or surgery. This is not a

strength problem but a sequencing problem. Patients who are given more traditionalstrength 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 andreinforce the Muscle Patterning component. This prevents effective recruitment of the cuff

muscles.

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"The 'Stanmore triangle' (a classification system for patients with shoulder instability) has

helped to recognise the importance of identifying those patients with instability with astructural component that will benefit from surgery and those that should primarily be a

conservative rehabilitation candidate. Muscle Patterning should generally be considered asa 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 tosurgically stabilise a shoulder with Muscle patterning with the pain and disability thatensues. 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 dueto 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. Optimalmuscle control results in maximal congruency of the bony structures.

"Scapula dyskinesis (abnormal scapula movement) is a common feature of shoulderinstability. 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 canhave 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 jointcongruency is lost. Furthermore this compromises the optimal length-tensionrelationships 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 managedpatients, and those post surgery, it is essential to rehabilitate optimal scapula mechanics

to ensure optimal congruency of the bony structures and optimal recruitment of thescapulo-humeral muscles."

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Article published: 31st October 2004

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