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Rawal A, Eckers F, Lee OSH, Hochreiter B, Wang KK, Ek ET. Current Evidence Regarding Shoulder Instability in the Paediatric and Adolescent Population. J Clin Med 2024; 13:724. [PMID: 38337418 PMCID: PMC10856087 DOI: 10.3390/jcm13030724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/18/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Paediatric and adolescent shoulder instability is caused by a unique combination of traumatic factors, ligamentous laxity, and pattern of muscle contractility. The multifactorial nature of its aetiology makes interpretation of the literature difficult as nomenclature is also highly variable. The purpose of this review is to summarize the existing literature and shed light on the nuances of paediatric and adolescent shoulder instability. The epidemiology, clinical features, imaging, and management of all forms of paediatric shoulder instability are presented. The main findings of this review are that structural abnormalities following a dislocation are uncommon in pre-pubertal paediatric patients. Young post-pubertal adolescents are at the highest risk of failure of non-operative management in the setting of traumatic instability with structural abnormality, and early stabilisation should be considered for these patients. Remplissage and the Latarjet procedure are safe treatment options for adolescents at high risk of recurrence, but the side-effect profile should be carefully considered. Patients who suffer from instability due to generalized ligamentous laxity benefit from a structured, long-term physiotherapy regimen, with surgery in the form of arthroscopic plication as a viable last resort. Those who suffer from a predominantly muscle patterning pathology do not benefit from surgery and require focus on regaining neuromuscular control.
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Affiliation(s)
- Aziz Rawal
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC 3181, Australia; (A.R.); (F.E.)
| | - Franziska Eckers
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC 3181, Australia; (A.R.); (F.E.)
- Orthopädie und Traumatologie, Universitätsspital Basel, 4031 Basel, Switzerland
| | - Olivia S. H. Lee
- Victorian Paediatric Rehabilitation Service, The Royal Children’s Hospital, Melbourne, VIC 3052, Australia;
| | - Bettina Hochreiter
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC 3181, Australia; (A.R.); (F.E.)
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, 8006 Zürich, Switzerland
| | - Kemble K. Wang
- Department of Orthopaedic Surgery, The Royal Children’s Hospital, Melbourne, VIC 3052, Australia;
| | - Eugene T. Ek
- Melbourne Orthopaedic Group, Windsor, Melbourne, VIC 3181, Australia; (A.R.); (F.E.)
- Department of Surgery, Monash University, Melbourne, VIC 3800, Australia
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Griffin J, Jaggi A, Daniell H, Chester R. A systematic review to compare physiotherapy treatment programmes for atraumatic shoulder instability. Shoulder Elbow 2023; 15:448-460. [PMID: 37538527 PMCID: PMC10395403 DOI: 10.1177/17585732221080730] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/15/2022] [Accepted: 01/17/2022] [Indexed: 08/05/2023]
Abstract
Background Optimal physiotherapy treatment is uncertain for atraumatic shoulder instability (ASI), the primary aim of this systematic scoping review was to compare physiotherapy treatment programmes for people with ASI. The secondary aims were to evaluate outcome measures used and to compare the effectiveness of these programmes. Methods CINAHL, EMBASE and Medline databases were searched for studies, except single case studies, published between 1950 and July 2021. 12 critical appraisal items covered three domains; internal validity, transferability to wider population and reporting. Results Ten studies were included; one randomised controlled trial, 6 cohort studies and 3 case series. There were 491 participants. Treatment programmes included education, movement re-education, static posture correction, shoulder muscle strengthening, functional training, and adjuncts. All studies used patient reported outcome measures (PROMs), 7 of which reported a statistically significant improvement (p < 0.05) post-treatment. There was no clear relationship between programmes and outcomes. PROMs specific to shoulder instability were all found to detect statistically significant differences post-treatment. Discussion There does not appear to be one optimal physiotherapy treatment programme for ASI. Future studies should use PROMs that are valid in the shoulder instability population and use more outcome measures that are specific to impairments being targeted.
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Affiliation(s)
- Jake Griffin
- Bexley MSK, Oxleas NHS Foundation Trust, Erith and District Hospital, Erith, DA8 3EE, UK
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
| | - Anju Jaggi
- Physiotherapy Department, Royal National Orthopaedic Hospital NHS Trust, Stanmore, London, UK
| | - Helena Daniell
- Physiotherapy Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK
| | - Rachel Chester
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, Norfolk, NR4 7TJ, UK
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Livett MF, Williams D, Potter H, Cairns M. Functional cortical changes associated with shoulder instability - a systematic review. Shoulder Elbow 2022; 14:452-464. [PMID: 35846404 PMCID: PMC9284298 DOI: 10.1177/17585732211019016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Glenohumeral joint instability is associated with structural deficits and/or alterations in sensory and motor processing; however, a proportion of patients with glenohumeral joint instability fail to respond to surgical and rehabilitative measures. This systematic review aimed to establish if functional cortical changes occur in patients with glenohumeral joint instability. METHODS AMED, CINAHL, Cochrane Central Register of Controlled Trials, Embase, Medline, PEDro, Pubmed, PsychINFO and Scopus were searched from inception to 17 March 2021. Randomised controlled trials and non-randomised trials were included and quality was appraised using the Downs and Black tool. RESULTS One thousand two hundred seventy-nine records were identified of which five were included in the review. All studies showed altered cortical function when comparing instability patients with healthy controls and included areas associated with higher cortical functions. DISCUSSION The findings of this systematic review offer some insight as to why interventions addressing peripheral pathoanatomical factors in patients with glenohumeral joint instability may fail in some cases due to functional cortical changes. However, data are of moderate to high risk of bias. Further high-quality research is required to ascertain the degree of functional cortical changes associated with the type and duration of glenohumeral joint instability.
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Affiliation(s)
- Morissa F Livett
- School of Health and Social Work, University of Hertfordshire, Hatfield, UK,Morissa F Livett, Cornwall Partnership NHS
Foundation Trust, Bodmin Community Hospital, Boundary Road, Bodmin, Cornwall
PL31 2QT, UK.
| | | | - Hayley Potter
- Cornwall Partnership NHS Foundation
Trust, Bodmin, UK
| | - Melinda Cairns
- School of Health and Social Work, University of Hertfordshire, Hatfield, UK
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Philp F, Faux-Nightingale A, Woolley S, de Quincey E, Pandyan A. Evaluating the clinical decision making of physiotherapists in the assessment and management of paediatric shoulder instability. Physiotherapy 2021; 115:46-57. [DOI: 10.1016/j.physio.2021.12.330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 10/21/2021] [Accepted: 12/21/2021] [Indexed: 11/29/2022]
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Coulthard C, Cairns MC, Williams D, Hughes B, Jaggi A. Management of atraumatic shoulder instability in physiotherapy (MASIP): a survey of physiotherapy practice. BMC Musculoskelet Disord 2021; 22:840. [PMID: 34592969 PMCID: PMC8485495 DOI: 10.1186/s12891-021-04677-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 08/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The impact of atraumatic shoulder instability (ASI) on patients can be extensive, its management complex, with a biopsychosocial approach recommended. Currently how physiotherapists manage ASI is unknown or the extent to which current clinical practice aligns with existing evidence. At the time of this study no national guidelines or consensus to direct practice existed. METHODS A cross-sectional electronic survey was distributed between July-September 2018, targeting UK-based physiotherapists managing shoulder pathology. Respondents were invited to describe their management of ASI, and rate their awareness and utilisation of various treatment techniques on a Likert-scale; median and interquartile ranges were calculated. Free text survey items were analysed using quantitative content analysis (QCA) to identify codes and categories. Means and percentages were calculated to summarise QCA and descriptive data. RESULTS Valid survey responses were analysed (n = 135). Respondents had between 2 and 39 years of physiotherapy experience (mean = 13.9 years); the majority (71.1 %) reported that ASI made up < 10 % of their caseload. Only 22.9 % (n = 31/135) of respondents reported feeling 'very confident' in managing ASI; the majority feeling 'somewhat confident' (70.4 %, n = 95/135) or 'not confident' (6.7 %, n = 9/135). The majority of respondents (59.3 %) used an ASI classification system, > 90 % citing the Stanmore Classification. Physiotherapists adapted their management according to clinical presentation, responding to differing biopsychosocial needs of the patient scenario. Most respondents (> 80 %) did not use a protocol to guide their management. Exercise was the most utilised management approach for ASI, followed by education; novel treatment strategies, including cortical rehabilitation, were also reported. CONCLUSION Findings indicate physiotherapists utilise a wide range of treatment strategies and respond to biopsychosocial cues when managing patients with ASI. The majority reported not being very confident in managing this condition, however only a minority use rehabilitation protocols to support their management. Some interventions that respondents reported using lacked evidence to support their use in ASI management and further research regarding effectiveness is required. Guidelines have been published since this survey; the impact of these will need evaluating to determine their effectiveness in the future.
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Affiliation(s)
- Caroline Coulthard
- Surrey iMSK Service, Ashford and St. Peter's Hospitals NHS Foundation Trust, Guildford Road, Chertsey, Surrey, KT16 0PZ, UK.
| | - Mindy C Cairns
- School of Health and Social Work, University of Hertfordshire, Hatfield, Hertfordshire, AL10 9AB, UK
| | - Deborah Williams
- The Shoulder & Elbow Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| | - Ben Hughes
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, WN6 9EP, UK
| | - Anju Jaggi
- The Shoulder & Elbow Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
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Hashim SSR, Sau N, Trickett T, Jaggi A, Eastwood DM. Medical Interactive Recovery Assistant: a useful clinical tool in paediatric shoulder rehabilitation? INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2021. [DOI: 10.12968/ijtr.2019.0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background/aims Outpatient physical therapy is the mainstay of treatment in shoulder instability, but lack of motivation and intermittent monitoring of progress is associated with poor compliance. ‘Exergames’ (a combination of videogames and physical exercise) may provide an additional or alternative motivational factor. The aim of this study was to determine the applicability of the Medical Interactive Recovery Assistant Xbox Kinect gaming software in the management of adolescent atraumatic shoulder instability. Methods Patients completed six 30-minute sessions playing games using the Medical Interactive Recovery Assistant while participating in a therapy programme. Pain and fatigue questionnaires, functional assessments and a framework analysis of free-text comments were used. Results A total of 20 female patients (15 unilateral, five bilateral pathology, mean age 14.1 years) completed the sessions. An average session length was 10.8 mins (range 0–24 mins). After each session using the Medical Interactive Recovery Assistant, 80% were neither in pain, nor overly tired. At 2 weeks, the Stanmore Percentage of Normal Shoulder Assessment scores had improved by a mean 17.9% and 10 (50%) patients showed improvements in Oxford Shoulder Instability Scores. Overall, 15 participants (75%) liked the technology; however six (32%) preferred standard physiotherapy, because of software limitations and lack of personal interaction. Conclusions Medical Interactive Recovery Assistant gamification is applicable for this patient cohort and could be integrated into adolescent atraumatic shoulder instability rehabilitation programmes; however, results emphasise the importance of personal contact.
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Affiliation(s)
| | - Nasreen Sau
- Department of Physiotherapy, Royal National Orthopaedic Hospital, London, UK
| | - Toni Trickett
- Department of Physiotherapy, Royal National Orthopaedic Hospital, London, UK
| | - Anju Jaggi
- Department of Physiotherapy, Royal National Orthopaedic Hospital, London, UK
| | - Deborah M Eastwood
- Department of Physiotherapy, Royal National Orthopaedic Hospital, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
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Noorani A, Goldring M, Jaggi A, Gibson J, Rees J, Bateman M, Falworth M, Brownson P. BESS/BOA patient care pathways: Atraumatic shoulder instability. Shoulder Elbow 2019; 11:60-70. [PMID: 30719099 PMCID: PMC6348586 DOI: 10.1177/1758573218815002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ali Noorani
- St Bartholomew's and the Royal London Hospital, London, UK
| | | | - Anju Jaggi
- Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | - Jo Gibson
- Royal Liverpool University Hospital, Liverpool, UK
| | - Jonathan Rees
- Botnar Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Marcus Bateman
- Derby Shoulder Unit, University Hospitals of Derby & Burton NHS Foundation Trust, Derby, UK
| | - Mark Falworth
- Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
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Watson L, Balster S, Warby SA, Sadi J, Hoy G, Pizzari T. A comprehensive rehabilitation program for posterior instability of the shoulder. J Hand Ther 2018. [PMID: 28641736 DOI: 10.1016/j.jht.2017.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Posterior shoulder instability is recognised as being less prevalent than anterior instability, however the diagnosis of this pathology is easily overlooked or missed and this may contribute to an underestimation of prevalence. Recently, there has been increasing recognition of this condition and consequently a greater requirement for knowledge of diagnostic procedures and treatment directions. Currently there is limited research into the conservative management of posterior instability, although it is recommended as first-line treatment prior to surgical review, particularly in those with an atraumatic instability mechanism. The aim of this paper is to outline a comprehensive rehabilitation program for the conservative management of posterior instability with a focus on scapular and humeral head control. The information provided includes extensive written information, flowcharts, figures and a table of management parameters that will provide therapists with adequate detail to replicate the program in the clinical setting.
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Affiliation(s)
- Lyn Watson
- Department of Rehabilitation, Nutrition and Sport, College of Science, Health and Engineering, La Trobe University, Bundoora, Victoria, Australia; LifeCare Prahran Sports Medicine Centre, Prahran, Victoria, Australia; Melbourne Orthopedic Group, Melbourne, Victoria, Australia
| | - Simon Balster
- LifeCare Prahran Sports Medicine Centre, Prahran, Victoria, Australia; Melbourne Orthopedic Group, Melbourne, Victoria, Australia
| | - Sarah Ann Warby
- Department of Rehabilitation, Nutrition and Sport, College of Science, Health and Engineering, La Trobe University, Bundoora, Victoria, Australia; LifeCare Prahran Sports Medicine Centre, Prahran, Victoria, Australia; Melbourne Orthopedic Group, Melbourne, Victoria, Australia
| | | | - Greg Hoy
- Melbourne Orthopedic Group, Melbourne, Victoria, Australia
| | - Tania Pizzari
- Department of Rehabilitation, Nutrition and Sport, College of Science, Health and Engineering, La Trobe University, Bundoora, Victoria, Australia.
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Jaggi A, Alexander S. Rehabilitation for Shoulder Instability - Current Approaches. Open Orthop J 2017; 11:957-971. [PMID: 28979601 PMCID: PMC5611703 DOI: 10.2174/1874325001711010957] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 10/24/2016] [Accepted: 10/28/2016] [Indexed: 11/22/2022] Open
Abstract
Background: The shoulder relies predominantly on dynamic muscular control to provide stability. Successful treatment is highly dependent upon the correct clinical diagnosis, identification of anatomical structural defects and abnormal movement patterns so that rehabilitation programs can be designed accordingly and individualised to the patient. Method: A systematic outline is provided to guide the clinician on how to identify muscular insufficiencies both local to the shoulder joint and global muscles that can influence shoulder instability. Management is based on expert experience and current literature. Results: The Stanmore classification helps to correctly diagnose the type of instability and prioritise management. Symptom modification tests can help to guide management, however assessing individual muscle groups local to glenohumeral control is also recommended. Conclusion: Physical and psychosocial factors can influence motor control in the presence of pain and injury. A multi-disciplinary approach is required to avoid recurrence of symptoms with rehabilitation focusing on kinetic chain, scapular and gleno-humeral control.
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Affiliation(s)
- Anju Jaggi
- RNOHT - Therapies Dept Brockley Hill Stanmore Middlesex Stanmore HA7 4LP United Kingdom
| | - Susan Alexander
- RNOHT - Therapies Dept Brockley Hill Stanmore Middlesex Stanmore HA7 4LP United Kingdom
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Watson L, Warby S, Balster S, Lenssen R, Pizzari T. The treatment of multidirectional instability of the shoulder with a rehabilitation program: Part 1. Shoulder Elbow 2016; 8:271-8. [PMID: 27660660 PMCID: PMC5023053 DOI: 10.1177/1758573216652086] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 04/26/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The most commonly recommended initial treatment for multidirectional instability is a rehabilitation program. Although there is evidence to support the effect of conservative management on this condition, the published literature provides little information on the exercise parameters of such programs. In addition, current published rehabilitation programs for multidirectional instability do not focus on scapula stability or exercise drills into functional and sports-specific positions, which are often important aspects to consider in this patient population. METHODS The aim of this paper (Part 1) is to outline the first two stages of a six-stage rehabilitation program for the conservative management of multidirectional instability with a focus on scapula control and exercise drills into functional positions. RESULTS AND CONCLUSIONS This clinical protocol is currently being tested for efficacy as part of a randomized controlled trial (Australian New Zealand Clinical Trials Registry #ACTRN12613001240730). The information in this paper and additional online supplementary files will provide therapists with adequate detail to replicate the rehabilitation program in the clinical setting.
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Affiliation(s)
- Lyn Watson
- LifeCare Prahran Sports Medicine Centre, Prahran, Victoria, Australia
- La Trobe University, College of Science, Health and Engineering, School of Allied Health, Department of Rehabilitation, Nutrition and Sport, Bundoora, Victoria 3086, Australia
| | - Sarah Warby
- LifeCare Prahran Sports Medicine Centre, Prahran, Victoria, Australia
- La Trobe University, College of Science, Health and Engineering, School of Allied Health, Department of Rehabilitation, Nutrition and Sport, Bundoora, Victoria 3086, Australia
| | - Simon Balster
- LifeCare Prahran Sports Medicine Centre, Prahran, Victoria, Australia
| | - Ross Lenssen
- LifeCare Prahran Sports Medicine Centre, Prahran, Victoria, Australia
- La Trobe University, College of Science, Health and Engineering, School of Allied Health, Department of Rehabilitation, Nutrition and Sport, Bundoora, Victoria 3086, Australia
| | - Tania Pizzari
- La Trobe University, College of Science, Health and Engineering, School of Allied Health, Department of Rehabilitation, Nutrition and Sport, Bundoora, Victoria 3086, Australia
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Abstract
Elbow stiffness is a common consequence following trauma with the management of this condition posing a challenge to therapists and surgeons alike. This paper discusses the role of conservative treatment, such as exercise and splinting, in the prevention and management of the stiff elbow, along with a review of available evidence, to justify their usage.
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Affiliation(s)
- Val Jones
- Val Jones, Sheffield Shoulder & Elbow Unit, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK. Tel: +44 01142 714857.
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