Effectiveness of Conservative Treatment for MDI 

Gregory Sabo

Objectives

•Define the current clinical scenario and question•Identify search methods for the best available evidence

for successful treatment of MDI•Describe the findings of these key studies•Address the weaknesses of these key studies•Summarize the implications for practitioners

Multidirectional Instability (MDI)

•Numerous etiologiesoTraumaticoAtraumaticoCongenitaloMultifactorial 

•Symptomatic global laxity ofglenohumeral joint•Generally younger, active

o<30•Men = Women•Orthopedic Research Institute defines as glenohumeral

instability in >1 direction

•Different from unidirectional instability

http://test2.aaos.org/oko/topic_images/SPO041.jpg

Clinical Scenario

•Complex pathology, difficult to treat•Two common intervention

approacheso Surgery ->

Immobilization -> PToConservative PT

management  •Conflicting data to suggest

which is best•Specific pt populations may

benefit morefrom one approach vs. another http://redsports.sg/wp-content/uploads/2008/04/clunking-shoulder.jpg

Dynamic and Static Restraints•Labrum and capsule •Rotator cuff muscles•Sup/middle/inf

glenohumeral ligaments•Orientation and size of

the humeral head and glenoid •Also the coracoacromial lig,

axillary pouch, and

Scapulothoracic muscles and orientation

Clinical Scenario Patient Symptoms

•Loosening of the shoulder in all directions

•This my be pronounced while carrying luggage

or turning over while asleep

•Pain may or may not be present

•Sulcus sign

•Patient may feel shoulder slippage or feeling of insecurity with specific activities

•May have normal observation, AROM, PROM, RROM (in test positions), normal imaging

Special Tests•Rowe Test for MDI

•Sulcus sign

•Load and shift

•Anterior and posterior

drawer in standing or sitting

•Joint glides in supine

•Push-pull test

Grades of Humeral Head Translation

Normal laxity- mild amount of translation up to 25%

Grade 1- A feeling of the humeral head riding up to the glenoid rim 25-50%

Grade 2- A feeling of the humeral head over riding the rim, but spontaneously reduces >50%

Grade 3- A feeling of the humeral head over the rim, but remains dislocated

Focused Clinical Question

Is conservative rehabilitation alone an effective intervention in the treatment of multidirectional shoulder instability?

Search Strategy

P- Multidirectional shoulder instability

I- Conservative treatment OR therapeutic exercise OR       non-invasive treatment OR strengthening exercise

C- Invasive treatment OR surgery OR capsular shift

O- Presence of symptoms OR recurrence of dislocation/subluxation OR return to function

Search Strategy Cont'd

•Databases used:oPubmedoCINAHLoSPORTDiscusoPEDro

•Inclusion criteria:oStudies investigating effectiveness of conservative

treatmentoEnglish languageoHuman participantsoLast 10 yearsoStrengthening regimen 

Search Strategy Cont'd

•Exclusion criteria:oStudies investigating unidirectional instabilityoPatients with current soft tissue or bone injuryoPatients with history of shoulder surgeryoAnimal models 

Search Results

 

Capsular Shift Surgery

•Capsular shift surgery is the tightening of the capsule,

“shifting” it back into place so that it helps hold the

joint together. It is usually done as an “open” procedure

assisted by an arthroscopy, which is the viewing of the

joint through a magnified scope. The patient is usually

placed into a semi-sitting position on a special bed with

a back that raises up. The patient’s head is stabilized

in a soft, padded head holder.

•Once the capsule is viewed through the arthroscope and the area of damage located, the open incision is made. The stretched capsule is brought forward and pulled tighter by folding over itself. It is then sutured into place with strong, absorbable sutures.

Illyés et al (2009)Study Design

Prospective Cohort

Participants

101 subjects Control Group: 32 males, 18 females, average age in mid 20’s PT Group: 17 males, 15 females, average age 18 Surgery + PT Group: 7 males, 12 females, average age in low 30’s

Intervention

Conservative Group: Education, Mirrors, PNF, biofeedback, strengthening exercises,closed chain exercises, stamina training Surgical Group: Open capsular shift, immobilized in sling for 6 weeks, rehab on day 1:aarom elevation to 90, ER to 10 degrees. After 3 weeks: max ROM without pain. After 6 weeks: Begin same intervention as conservative group

Outcome Measures

EMG data from pec major, infraspinatus, deltoid, uppertrapezius, bicep, tricep, during pull, forward punch, elevation, slow/fast overhead throw Time between first muscle reaching max activity and last (time broadness) Normalized maximum amplitudes

Main Findings

Only surgical + rehab returned muscles activity to normal Motion patterns on muscles around joint with MDI are changed. Conservative treatment improved time broadnessto normal, but not for level of muscle activations (decreased accelerators, increasedstabilizers). Surgical treatment improved time broadness and level of muscle activation tonormal.

Level of Evidence

2B

Conclusion

Conservative treatment alone is not enough to return muscle activation patterns tonormal on a shoulder with MDI.

Kiss et al (2010)Study Design

Non-Randomized Control Trial

Participants

90 subjects Control Group: 16 males, 9 females, average age 27 PT Group: 18 males, 16 females, average age 28 Surgery + PT Group: 12 males, 19 females, average age 30

Intervention

Program consisted of proprioceptive input to improve the sense of joint position, and on relearning correct movement patterns with the development of strength and endurance in the scapulothoracic and glenohumeral muscles. Mirrors, PNF, biofeedback were used to retrain patterns of ST and GH movement. Strength exercises, closed chain exercises, stamina training were used to increase stability of muscle balance and proprioception. Surgery group had a capsular shift using the “beach chair” position through an anterior approach. Surgery was then followed with postoperative physiotherapy.

Outcome Measures

Kinematic characteristics of movement measured using the Zebris CMS-HS movement analysis system. Changes in the electrical potential of the ant/middle/post parts of the deltoid, supraspinatus with trapezius, infraspinatus, biceps brachii, triceps brachii were recorded. Maximum muscle contraction was specified by taking the highest muscle contraction achieved during various forms of motion. Bilinear regression line of rhythm was calculated using 5 parameters of motion pattern.

Main Findings

Patients with MDI had significant alterations in shoulder kinematics and in muscle activity compared to controls. Short term and long term PT by strengthening the rotator cuff, triceps, serratus and deltoid muscles did not restore the motion and duration of the muscular activity of the shoulder joint. Capsular shift and postoperative physiotherapy restored the motion and duration of the muscular activity of the shoulder joint.

Level of Evidence

2B

Conclusion

The study’s comprehensive set of functional tests indicated that surgery with post op PT resolved labral and ligamentous abnormalities by surgical treatment, and restored impaired muscular control by postoperative rehabilitation. Whereas, PT only increases neuromuscular control at shoulder joints. Capsular shift with sufficient conservative PT enables bilinear scapulothoracic and glenohumeral rhythms and the normal relative displacement between the rotation centers of the scapula and humerus to be restored. The duration of muscular activity was almost normal after surgery with post op PT. The labrum, ligaments, and paired muscular control collectively stabilized the shoulder joint during motion.

Misamore et al (2005)Study Design

Uncontrolled, Retrospective, Noncomparative Review

Participants

64 patients with atraumatic MDI 21 males, 43 females, average age 18.6 All but 9 participated in sport

Intervention

Enrolled in physical therapy program and were placed on home exercise program. Phase 1 consisted of relative rest from provocative activities, analgesics, and gentle ROM exercises. Phase 2 consisted of rotator cuff and parascapular muscle strengthening exercises. Slow progressive strengthening programs were performed daily at home (15 to 20 min 3x daily). Phase 3 involved sport specific exercises if appropriate. Phase 4 involved returning to sport or work.

Outcome Measures

Modified Rowe score (Max of 100 points). Includes function, pain, stability, motion.

Main Findings

At 2 years surgery had been performed on 20 of the patients to stabilize their shoulder. Of the 39 patients not receiving surgery 20 had good or excellent results regarding pain relief, 21 had good or excellent results with stability, 28 reported that the shoulder condition was better or much better. At 8 years 1 addition patient received surgery. Of the 36 non-surgical patients 29 reported no further treatment for their shoulder instability, none of the patients were still performing shoulder therapy exercises. 28 reported persistent problems with their shoulders, 8 reported no residual symptoms.

Level of Evidence

2B

Conclusion

At the 8 year follow up 40 of 57 patients (70%) had been treated surgically or had fair or poor ratings for their shoulders. Only 30% had a good or excellent result based on the modified Rowe score. The data suggests that most patients who improve with the exercise program do so fairly quickly, usually responding within 3 months. Those patients who were treated surgically seemed to benefit less from strengthening exercises.

Ide et al (2003)Study Design

Prospective Cohort

Participants

46 patients with MDI 12 males, 34 females, average age 20

Intervention

Prescribed exercise daily for 8 weeks. Performed exercise in novel shoulder orthosis to increase scapular inclination and to stabilize the scapula. Strengthening the rotator muscles and scapular stabilizers (serratus anterior, and rhomboids). Isometric exercises included IR, ER, and isotonic shoulder strengthening exercises with thera-band. Wall pushup exercises to strengthen scapular stabilizers and synchrony training of the scapulothoracic muscles.

Outcome Measures

Before and after 8 week program patients were evaluated for; shoulder function, pain, numbness, stability, ROM on a modified Rowe grading system. There was then a follow up at 7 years.

Main Findings

Before the rehab program 59 shoulders were in fair condition and 14 were in poor condition. After the rehab program 24 shoulders were in fair condition and 1 was in poor. Muscle strength increased by more than 20% in 22 of 36 shoulders, in 20 of 22 shoulders good or excellent results were achieved.

Level of Evidence

2B

Conclusion

The aim of rehabilitation should be a gain of 20% in the peak torque of internal and external rotation and the achievement of normal muscle balance. Shoulder orthotic prevents a decrease in scapular inclination; rather, it increases scapular inclination by pushing the inferior angle of the scapula and straightening the thoracic spine. Patients can achieve stabilization of the glenohumeral joint and scapula by using the orthosis correctly. They are permitted to remove the orthosis after achieving strengthening of the shoulder muscles upon completion of the exercise program.

Gibson et al (2004)Study Design

Systematic Review

Participants

Adults 16-55 with history of shoulder instability Excluded stroke, hemiplegia, prior surgery

Intervention

Non-operative management including but not limited to immobilization and PT methods like stretching, strengthening or stabilization exercises, biofeedback, other modalities

Outcome Measures

Recurrence of instability (redislocation or resubluxation) Return topremorbid function Alleviation of symptoms

Main Findings

Many different intervention protocols, but mostly based on physiological rationaleand biological evidence Paucity of quality trials in this area Reviewlimited to qualitative analysis due to poor reporting in many papers Current available studies are weak foundation Weak but positive trend for conservative management Most cohorts found worse outcome with conservative management, particularly in those under 30.

Level of Evidence

1A

Conclusion

Weak evidence to support surgery over conservative management.

Current Conservative Management American College of Sports Medicine recommends strengthening of the scapulothoracic and glenohumeral muscles

Scapulothoracic

Movement

Muscle

Resistance exercise

Fixation

Serratus ant

Push up

Fixation

Pec minor

Parallel bar dip

Fixation

Trap Upright row

Fixation

Levatorscapulae

Shoulder shrug

Fixation

Rhomboids

Seated row

Current Conservative Management

Glenohumeral

Movement

Muscle Resistance exercise

Flexion Ant deltFront raises

Pec major (clavicular head)

Incline bench press

Extension

Latissimus dorsi

Dumbbell pull-over

Teres major

Chin-up

Pec major (sternocostal head)

Bench press

Current Conservative Management

Glenohumeral

Movement

Muscle Resistance exercise

Abduction

Middle delt

Lateral raises

Suprspinatus

Low pulley lateral raises

Adduction

Latissimus dorsi

Lat pull-down

Teres major

Seated row

Pec major

Cable crossover fly

Current Conservative Management

Glenohumeral

Movement

Muscle Resistance exercise

Internal rotation

Teres major

Bent row

Subscapularis

One-arm dumbbell row

Pec major

Bench press

Ant deltFront raises

External rotation

Infraspinatus

External rotation

Teres minor

External rotation

Post delt

Bent-over lateral raises

Study findings affecting conservative management

Study 1 Patients with MDI have altered motion patterns on muscles around joint

Study 2 Patients with MDI had significant alterations in shoulder kinematics and in muscle activation

Study 3 Most patients who improve with ther ex program do so fairly quickly, usually within the first 3 months.Pts who had surgery seemed to benefit less from strengthening exercises during conservative treatment

Study 4 Aim of rehab should be to gain 20% in peak torque of IR and ER and the achievement of normal muscle balance

Study 5 Weak but positive trend for conservative management

Summary and Clinical Implications

•Paucity of good quality studiesoWeak foundation for future research

•Weak evidence to support surgery as a necessity•Weak evidence to support conservative intervention alone•Conservative intervention should remain first line

oImprovements should be noticeable earlyAbsence an indication for surgery

oMost patients will need surgery• Following surgery

o3-4 weeks immobilizationo12 weeks of Scapular/Glenohumeral strengthening and

stability exerciseso EMG biofeedback can be used in adjunct

Gibson, K., A. Growse, L. Korda, E. Wray, and JC MacDermid. "The Effectiveness of Rehabilitation for Nonoperative Management of Shoulder Instability: a Systematic Review." Journal of Hand Therapy 17.2 (2004): 229-42.

Ide, J., S. Maeda, M. Yamaga, K. Morisawa, and K. Takagi. "Shoulder-strengthening Exercise with an Orthosis for Multidirectional Shoulder Instability: Quantitative Evaluation of Rotational Shoulder Strength before and after the Exercise Program." Journal of Shoulder and Elbow Surgery 12.4 (2003): 342-45.

Illyes, A., J. Kiss, and R. Kiss. "Electromyographic Analysis during Pull, Forward Punch, Elevation and Overhead Throw after Conservative Treatment or Capsular Shift at Patient with Multidirectional Shoulder Joint Instability." Journal of Electromyography and Kinesiology (2008).

Kiss, Rita M., Árpád Illyés, and Jenő Kiss. "Physiotherapy vs. Capsular Shift and Physiotherapy in Multidirectional Shoulder Joint Instability." Journal of Electromyography and Kinesiology (2009).

Misamore, G., P. Sallay, and W. Didelot. "A Longitudinal Study of Patients with Multidirectional Instability of the Shoulder with Seven- to Ten-year Follow-up." Journal of Shoulder and Elbow Surgery 14.5 (2005): 466-70.

American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise Testing and Perscription. 6th ed. Wolters Kluwer; 2010: 1-868.

David J. Magee. Orthopedic Physical Assessment. 5th ed. Saunders Elsevier; 2008: 231-360.

Questions?