Atraumatic/MDI - Physiotherapy Principles and Management

Atraumatic/MDI –physiotherapy principles and

managementTanya Anne Mackenzie

Research – does the evidence help?

what do we want to know from research?

In the MDI Sh:• What are the kinematics – know normal - what occurs in the MDI sh?• What are the M activation patterns in the MDI sh?- influence on rehab?• Leading to best conservative intervention?

problems with interpreting research Discrepancies in the precise definition, classification & pathogenesis of MDI?

• occurs in multiple directions with insignificant trauma• classification is based on the acronyms as in TUBS & AMBRI• Generalised looseness of the sh• Abnormal excursion of the HOH in the glenoid in all directions• Instability in 2 direction• Instability in 3 directions• Instability inferiorly with one of either anterior or posterior instability• Polar types on Stanmore triangle – still a spectrum

(Warby, Pizzari, Ford, Hahne, & Watson, 2014) (Longo et al., 2015)

problems with interpreting researchDiffering diagnostic criteria for MDI for inclusion in the study?

Heterogeneity of populations

MDI mixed with traumatic unidirectional & traumatic + MDI


problems with interpreting research

Hx of trauma are more likely to have a structural lesion

Pts with a structural lesion have better outcomes after Sx

In studies:• No differentiation subjects who had trauma with those that had no trauma• no imaging to rule out a structural lesion• Therefore, studies include subjects with MDI who also have also co-pathology in sh


Will influence outcomes

problems with interpreting researchOutcome measures (OM) – scoring not specific to this condition.(CONSTANT/ASES/ROWE etc )

OM used across all of the included studies were• impairment-only OM• OM not specific to measuring changes in the instability population.• Therefore, OM that were insensitive to clinical changes in the instability population


problems with interpreting research

Interventions:

• lack of standardisation of the rehab interventions

• Only a brief summary of their programmes – unable to replicate

• When comparing to conservative to Sx intervention – In Sx group -Variation in

Sx done within same study studies.


Quantitative…… Qualitative….

pathomechanics - drivers

challenge = find the driver

(Warby, Pizzari, Ford, Hahne, & Watson, 2014) (Barrett, 2015)

non-traumatic sh instability

(MDI)

secondary psychologicalemotional & cognitive factors

anatomical or neural defects acquired or geneticredundant anterior capsulebony and capsulolabral anatomy

mechano sensitivity neural tissue

Motor development poor muscle tonepoor sensory integration

Hyperlaxitygeneralised or congenital syndromes

Painperipheral (somatic)central sensitisation (neuropathic)changes in sensory and motor cortical representation

Movement dysfunctionneuromuscular controlscapula kinematicsatypical patterns of muscular activationProprioception loss

micro trauma

Complex patients and complex conditions to unravel

pathomechanics – drivers

challenge = drivers out of

physio control



(MDI)








micro trauma


Brain wave drivers



(MDI)








micro trauma

Growing Evidence

When compared MDI with controls• Change in threshold corticospinal response in LT and In Spin• ↓feedback mechanism• Altered neural control

(Alexander CM 2007Hundza & Zehr 2007)

Changes in cortical representation - Cortical drivers

Physio challenge to reverse the arrows

Manifests in complex patients

Cortical re-organisation• Anxiety and emotional regulation• Fear net work – neurotags• Loss of precision• Disrupted mvt motor control• Changes in sensory function• Alteration in perception of body part• ? Hx Neurodevelopment delay

• Yamaoto et al., 2015; Safran et al., 2010; Milgrom et al 2014)

Neurodevelopment & altered body perception = alarm bells avoid Sx

• Reciprocal limitations on tasks / rhythm/separate each side of the body/ coordination/ R hand L hand judgement

• Two point discrimination (4.5cm =C/ 8.5cm in MDI)

• Pain/ catastrophising scores

• Ask developmental milestones

(Mosley et al, 2012, Howard et al, 2015)

How we influence the neurotags-Negative reinforcement vs positive reinforcement

• Lack of Support

• Misunderstood

• Attentions seeking behaviour

• Disengaged with normal activities

• Significant emotional issues

• Frequent AnE visits

• Beliefs re diagnosis

• Beliefs re Previous Tx

• Previous failed interventions

• How does physio alter neuro tags: what we say, how we listen, reverse the process via physical intervention and rehab

How can physio modalities help?

Focused sensory discriminationMotor imagery ( L/R judgement tasks)Mirror visual feedbackBody perception re-education visual input to increase somato-senory cortex responseCross midlineNeuro dev – crawling, rolling

(Serino er al, 2007; Mosley et al 2008, 2009.)

How can physio modalities help?

• Visual targets (lazer/ spots on a wall etc/Ha2Ha )• Feedback, such as visual cues, tactile cues, tape and demonstration,

• Boundary setting is a useful tool. • Clear rehabilitation parameters communicated.• The patient should be given achievable ‘homework’• Modify activity/technique/ergonomics/nb the gym

• key is that the patient is taking responsibilityfor self as a condition of ongoing treatment

(Serino er al, 2007; Mosley et al 2008, 2009.)


Drivers local to the shoulder



(MDI)








micro trauma

Mainstay Physio tool remains change biomechanical drivers at shoulder

• RC timing issues

• Scap dyskinesia

• ↓proprioception

• ↓fatigue resistance

• Balance issues( KC)

• Posture (KC)

• JPS

• FIRST SESSION change their symptoms = confidence, trust, belief system alters etc

atypical patterns of scapular muscularactivity as the driver

• A review

• MDI no clear pattern scapulothoracic M activity compared to healthy controls• contradictory results on scapulothoracic M activity patterns.• no consensus was found on M recruitment timing.(Struyf et al., 2011)

Evidence for scapular kinematic as a driver

MDI = high % Scap dyskinesia (Kibler et al., 2013)

The patterns tends to be:• ↑ upward rotation (Longo et al., 2015)

• ↓ upward rotation (Warby, Pizzari, Ford, Hahne, & Watson, 2015)

atypical patterns of GHJ muscular activity as the driver

Morris et al. (2004) (Barden et al., 2005) (Illyés et al., 2009) (Struyf et al., 2011) (Labriola, Lee, Debski, & McMahon, 2005)

-Dynamic M activity –concavity compression- resistance to translation

EMG vital to understanding the RC

• M activity levels MVC

• Patterns of m activity with in the RC

• Patterns of m activity between RC and other Ms

• Timing of onset of m activity

• Broadness of contraction

Reporting all = interpretation complicated BUT not reporting all O Measures = simplifies interpretation & skews interpretation

Care with interpretation or reporting of EMG studies:what can we glean from EMG?...simply put

Led to the

To date research has illustrated that the dynamic cuff:

RC Ms perform diff functn roles during dynamic motion (Wattanaprakornkul, Halaki, Boettcher, Cathers, & Ginn, 2011)

Eccentric to concentric strength ratios in the RC Ms are relevant (David et al., 1999)

RC activity is influenced by: • Plane of motion (Alenabi, Dal Maso, Tétreault, & Begon, n.d.) (Tardo, Halaki, Cathers, & Ginn, 2013)

• Range (arc) of motion (Alenabi, Dal Maso, Tétreault, & Begon, 2015)

• Velocity of motion• Fatigue (Teyhen et al., 2008.)

• Presence of symptoms & pathology (Reddy et al., 2000),.

Therefore, when rehabbing the RC take all into accountHawkes, D. H., Alizadehkhaiyat, O., Fisher, A. C., Kemp, G. J., Roebuck, M. M., & Frostick, S. P. (2012).

atypical patterns of muscular activity as the driver


Infraspinatus & supraspinatus

• But in MDI = premature deactivation just before the end of ER at 65°

• Concl: compromise the RC - stability to GHJ at a critical point



Posterior Deltoid

• Controls = eccentric posterior deltoid onset 46° before end IR

• MDI = only 12° before the end IR



Pectoralis major

In flex/ext & abd/add & IR/ER• MDI = maintained low levels of activity throughout mvt• Control subjects = distinct patterns of activation &

deactivation in separate phases.

SO does rehab change scapular kinematics & atypical M pattering

Biomechanical analysis of the effect of Ex alone has shown that significant alterations in kinematic parameters in Pts with MDI cannot be completely normalized by Ex.(Nyiri, Illyés, Kiss, & Kiss, 2010)

Atypical patterns of M activation in Pts with MDI may not be sufficiently restored withEx alone(Illyés, Kiss, & Kiss, 2009)(Barden, Balyk, Raso, Moreau, & Bagnall, 2005)

In MDI Shs PhysiosThey optimise them

Considerations when planning successful cuff rehab programs

Which RC M/ Ms need to be targeted in rehab?

aim to create synergy bet the RC Ms (balance)

aim to create synergy bet the RC & other sh girdle Ms

aim to alter RC timing – onset of m activation (latency)

aim to broaden or shorten time of RC contraction

What type of contraction (concentric or eccentric) needs rehab

Considerations when planning successful cuff rehab programs

what range of the M (inner, outer, or middle) needs rehab

What range/ plane of physiological motion needs rehab

Making the complex simple• Simply change body position: supine, Prone, Standing, whatever

• Simply alters where gravity is by altering body position and retest

(alters the function of the RC i.e. mover or stabiliser, alters type of contraction ie eccentric or concentric, alters range of muscle and physiological range)

• Simply add manual or a form of resistance to alter length of contraction, alter timing and create synergy or to bias a specific RC m.

• then add to the functional movement

Finally: Train into controlled position of vulnerability

Normalization of active ROM with special attention

to end ROM & critical vulnerable positons

references

• An, Y. H., & Friedman, R. J. (2000). Multidirectional instability of the GHJ Jt. The Orthopedic Clinics of North America, 31(2), 275–285.

• Barden, J. M., Balyk, R., Raso, V. J., Moreau, M., & Bagnall, K. (2005). Atypical Sh M activation in multidirectional instability. Clinical Neurophysiology: Official Journal of the International Federation of Clinical Neurophysiology, 116(8), 1846–1857. http://doi.org/10.1016/j.clinph.2005.04.019

• Barrett, C. (2015). The clinical physiotherapy assessment of non-traumatic Sh instability. Sh & Elbow, 7(1), 60–71. http://doi.org/10.1177/1758573214548934

• Bateman, M., Smith, B. E., Osborne, S. E., & Wilkes, S. R. (2015). Physiotherapy Tx for atraumatic recurrent Sh instability: early results of a specific exercise protocol using pathology-specific outcome measures. Sh & Elbow, 1758573215592266. http://doi.org/10.1177/1758573215592266

• Burkhead, W. Z., & Rockwood, C. A. (1992). Tx of instability of the Sh with an exercise program. The Journal of Bone & Jt Sx. American Volume, 74(6), 890–896.

• Illyés, Á., Kiss, J., & Kiss, R. M. (2009). Electromyographic analysis during pull, forward punch, elevation & overhead throw after conservative Tx or capsular shift at patient with multidirectional Sh Jt instability. Journal of Electromyography & Kinesiology, 19(6), e438–e447. http://doi.org/10.1016/j.jelekin.2008.09.008

• Kiss, J., Damrel, D., Mackie, A., Neumann, L., & Wallace, W. A. (2001). Non-operative Tx of multidirectional Sh instability. International Orthopaedics, 24(6), 354–357.

• Labriola, J. E., Lee, T. Q., Debski, R. E., & McMahon, P. J. (2005). Stability & instability of the GHJ Jt: The role of Sh Ms. Journal of Sh & Elbow Sx, 14(1, Supplement), S32–S38. http://doi.org/10.1016/j.jse.2004.09.014

• Longo, U. G., Rizzello, G., Loppini, M., Locher, J., Buchmann, S., Maffulli, N., & Denaro, V. (2015). Multidirectional Instability of the Sh: A Systematic Review. Arthroscopy: The Journal of Arthroscopic & Related Sx, 31(12), 2431–2443. http://doi.org/10.1016/j.arthro.2015.06.006

• Merolla, G., Cerciello, S., Chillemi, C., Paladini, P., Santis, E. D., & Porcellini, G. (2015). Multidirectional instability of the Sh: biomechanics, clinical presentation, & Tx strategies. European Journal of Orthopaedic Sx & Traumatology, 25(6), 975–985. http://doi.org/10.1007/s00590-015-1606-5

• Misamore, G. W., Sallay, P. I., & Didelot, W. (2005). A longitudinal study of Pts with multidirectional instability of the Sh with seven- to ten-year follow-up. Journal of Sh & Elbow Sx, 14(5), 466–470. http://doi.org/10.1016/j.jse.2004.11.006

• Nyiri, P., Illyés, A., Kiss, R., & Kiss, J. (2010). Intermediate biomechanical analysis of the effect of physiotherapy only compared with capsular shift & physiotherapy in multidirectional Sh instability. Journal of Sh & Elbow Sx / American Sh & Elbow +-Surgeons ... [et Al.], 19(6), 802–813. http://doi.org/10.1016/j.jse.2010.05.008

• Struyf, F., Nijs, J., Baeyens, J.-P., Mottram, S., & Meeusen, R. (2011). Scapular positioning & movement in unimpaired Shs, Sh impingement syndrome, & GHJ instability. Sc&inavian Journal of Medicine & Science in Sports, 21(3), 352–358. http://doi.org/10.1111/j.1600-0838.2010.01274.x

• Warby, S. A., Pizzari, T., Ford, J. J., Hahne, A. J., & Watson, L. (2015). Exercise-based management versus Sx for multidirectional instability of the GHJ Jt: a systematic review. British Journal of Sports Medicine, bjsports–2015–094970. http://doi.org/10.1136/bjsports-2015-094970

• Warner, J. J. P. (n.d.). Role of Proprioception in Pathoetiology of Sh Instabil... : Clinical Orthopaedics & Related Research. Retrieved May 26, 2015, from http://journals.lww.com/corr/Fulltext/1996/09000/Role_of_Proprioception_in_Pathoetiology_of.5.aspx

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Atraumatic/MDI - Physiotherapy Principles and Management