A.Jaggy Atraumatic Instab manag · 29102014 3 ScapulaStability’ Progression’ • Supine’’...
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29102014 1 Managing Atrauma2c Shoulder instability Anju Jaggi Consultant Physiotherapist/President of EUSSER [email protected] Tweet @anju jaggi Atrauma2c Structural Trauma2c Muscle PaLerning I II III Capacity for complexity Con2nuum of different ae2ologies What are the Drivers? Hyperlaxity Cuff & Deltoid insufficiency Primary Scapula Dyskinesis CNS Peripheral nervous System Motor Control • Fear/Avoidance • Disuse • Inhibi2on • Compensatory strategies • Pain • And so on..............
Transcript of A.Jaggy Atraumatic Instab manag · 29102014 3 ScapulaStability’ Progression’ • Supine’’...
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Managing Atrauma2c Shoulder instability
Anju Jaggi Consultant Physiotherapist/President of EUSSER
[email protected] Tweet @anju jaggi
Atrauma2c Structural
Trauma2c
Muscle PaLerning
I
II III
Capacity for complexity
Con2nuum of different ae2ologies
What are the Drivers? Hyperlaxity
Cuff & Deltoid insufficiency
Primary Scapula Dyskinesis
CNS
Peripheral nervous System
Motor Control
• Fear/Avoidance • Disuse • Inhibi2on • Compensatory strategies
• Pain • And so on..............
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One size does not fit all!
• Don’t base decisions on structural pathology alone
• Case weight the problem – Hyperlaxity – Psychology – Muscle inhibi2on
• Muscle paLerning – Cause or effect?
Assessment Algorithm
Ac2ve ROM
Abnormal
paLerns
Posture improvement
Scapula assistance
Cuff facilita2on
Normal PaLerns
Supine resisted cuff tes2ng
Prone +lag to RC strength
Improvement Tes2ng Scapula Stability Exs
Phase 1 – Weight Bearing
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Scapula Stability Progression
• Supine • Side Lying • Prone • Don’t forget scapula eleva2on commonly an issue in MDI
Direct Dynamic RC Assessment
Assess ac2ve shoulder ROM Use isometric rota2on strength tests Direct treatment to ‘underac2ve’ component of RC
Ac2vate the RC in the unstable range Some2mes a muscle is overac2ve because its
compensa2ng for inadequate control somewhere else
Ginn & Jaggi ICSES 2013
Direct Rotator Cuff Exs
# Its tough being a cuff!
# Don’t underes2mate the weight of your arm!
Changing LL BOS in pa2ents
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Does LL BOS affect RC recruitment?
Morita W, Alexander S, Jaggi A
• 20 Healthy subjects • SEMG on lower trunk and
posterior rotators • Tested MVC ER at neutral
and in ABD • Varied posi2ons
– Standing 2 legs – One leg – Tip toes – Wobble board – Prone Lying
• ↓ BOS – -‐ve affect on RC recruitment
• Core mm func2on to compensate for ↓ BOS
• Posture affected RC recruitment more than shoulder posi2on
• Specific RC exs – maximum recuitment in prone lying
Evidence?
No gold standard on how to manage atrauma2c shoulder instability
No RCTs or prospec2ve cohort studies
What’s best?
Early muscle ac2va2on
Reassurance
Avoid injury
Predic2ve factors
Early surgery?
Restore propriocep've input
Placebo affect
The Focus for Therapy
• Reassurance & focus • Damage is not always representa2ve of symptoms
• Assess the specifics of shoulder dysfunc2on
• Consider the implica2on of global chain stability
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Help us answer the ques2on!
Does stabilisation surgery followed by physiotherapy improve short & long term outcomes compared with physiotherapy alone?
Ms Anju Jaggi Associate Prof Karen Ginn Dr Susan Alexander Professor Len Funk Professor Rob Herbert
hLp://www.rnoh.nhs.uk/sites/default/files/par2cipant_info_sheet_-‐_version_3_clean_-‐_08.05.2013.pdf
