PROSPECTIVE 2 YEAR FOLLOW UP OF PATIENT- AND DIAGNOSIS- SPECIFIC SPECIALIST PHYSIOTHERAPY TREATMENT FOR PATIENTS WITH ATRAUMATIC SHOULDER INSTABILITY

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Archibald Stephens
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1 PROSPECTIVE 2 YEAR FOLLOW UP OF PATIENT- AND DIAGNOSIS- SPECIFIC SPECIALIST PHYSIOTHERAPY TREATMENT FOR PATIENTS WITH ATRAUMATIC SHOULDER INSTABILITY T Douglas, A Jaggi, S Grange, S Lambert III I II The Shoulder and Elbow Service Royal National Orthopaedic Hospital Stanmore, UK

2 Background Literature Systematic reviews show poor efficacy of physiotherapy for the management of shoulder instability (Gibson et al 2004) Conventional physiotherapy treatment shown to be ineffective for patients with muscle patterning (Type III) (Malone et al 2006) Retrospective study indicated specialist physiotherapy was shown to be effective in 80% of patients with muscle patterning (Malone et al 2006)

3 Research question To demonstrate the effectiveness of specialist physiotherapy in a group of patients with atraumatic shoulder instability

4 Method Patients referred to specialist physiotherapy unit with recurrent/persistent shoulder instability Prior to treatment: clinical assessment Oxford Instability Score (OIS) Dawson et al 1999 Stanmore Percentage Of Normality Shoulder Assessment (SPONSA) Roberts et al, submitted Outcomes at 6/12, 1 y, 2 y postal or telephone follow up

5 Classification- Stanmore Triangle (Lewis et al 2004) Traumatic I Muscle Patterning III Atraumatic Structural II

6 Patient - Specific Specialist Physiotherapy Closed chain exercises, core stability & postural retraining Biofeedback techniques - EMG/Pressure biofeedback Proprioceptive feedback - tape/omotrain/supports Visual feedback - mirrors/videos Pain management strategies: pacing, functional retraining, sleep, medication advice and work/school support

7 Results N = exclusions (5 BOTOX, 5 surgery) Mean age = 23 y (range 11-50) Mean Duration of symptoms = 5 y (4 m - 25 y) 21% lost to follow-up at 1 year; 27% at 2 years

8 Results F : M = 60 : 40 68% dominant side Mean Beighton Score 5 / 9 79% previous failed physiotherapy 18% previous failed surgery

9 Results 32% 68% In Patient vs Out Patient Treatment Alone

10 Results Mean no of treatments for In-patient stay = 7 (5-15) Mean no of treatments for Out-patients = 7 (1-24) Mean Total no of treatments = 11 Duration of treatment = 9 months (1-24) (10 patients still ongoing treatment after 2 years)

11 Outcome Measure Results * OIS new scoring system Initial Ax 6/12 12/12 24/12 OIS SPONSA OIS SPONSA OIS SPONSA OIS SPONSA 18 43% 27 61% 27 66% 28 67% A 10 point change in the OIS score between initial Ax and 2 year follow up A 24% improvement on the SPONSA

12 Results Deterioration (17%) Improvement (83%) >7 pts >5 pts >1 pt >1 pt > 5 pts >7 pts 4% 7% 17% 83% 71% 61% A 7 point change on the OIS indicates a minimally clinical important difference / true change for this patient cohort according to the Moser et al 2008 In the same study (Moser et al 2008), it was reported that a 4.5 point change can be interpreted as slightly or much better

13 Conclusion Specialist physiotherapy was shown to be effective in patients with atraumatic instability - 91% of which demonstrated a component of abnormal muscle patterning Patients maintained outcome at 2 years There was a significant gain despite previous failed treatment and a duration of symptoms with a mean of 5 years Similar demonstration of improvement as previous retrospective notes study (Malone et al 2006)

14 Thank you III I II Research Team: Tania Douglas, Acting Clinical Specialist Physiotherapist Anju Jaggi, Clinical Specialist Shoulder Physiotherapist Andre Le Leu, Senior Physiotherapist David Bradbrook, Senior Physiotherapist Richard Morford, Senior Physiotherapist Katie Monnington, Senior Physiotherapist Elaine Cobb, Senior Occupational Therapist Simon Grange, Academic Consultant Orthopaedic Surgeon Simon Lambert, Consultant Orthopaedic Surgeon James Douglas, Data Input Assistant

15 Results 16% 84% Percentage of Patients treated by Clinical Physiotherapy Specialist vs Rotational Physio

16 Limitations Drop out rate at 2 years was > 25% however the same patients did not drop out at 1year & 2 years This drop out rate reduces the significance of change, therefore a further study with larger numbers is required & an Intention To Treat Analysis may help to indicate more accurate outcome Limitations of questionnaires -return times -patient response bias Only subjective outcome was analysed

17 Future Studies Secondary Analyses Predictive outcome

18 Specialist Physiotherapy Biofeedback techniques EMG/Pressure biofeedback Proprioceptive feedback - tape/omotrain/supports Visual feedback - mirrors/videos

19 Additional Treatment Pain management strategies: pacing, functional retraining, sleep, medication advice and work/school support

RNOH EDUCATION. The Stanmore Therapies Series. Intelligent Rehabilitation Relating Brain to Muscle to Function

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