Dr Tanya Mackeznie presents latest evidence and current opinion on MDI/Atraumatic Shoulder Instability

1. MDI – rehab or surgery?
latest evidence
current opinion
clinical decision making
assess & tx tips
Tanya Anne Mackenzie PhD

2. Latest evidence
• Is there evidence to support one intervention for MDI over another?

3. 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 ant or posterior instability
• Polar types on Stanmore triangle – still a spectrum
(Warby, Pizzari, Ford, Hahne, & Watson, 2014) (Longo et al., 2015)

4. problems with interpreting research
the diagnostic criteria for MDI for inclusion in the study differs greatly
Heterogeneity of populations
MDI mixed with traumatic/atraumatic unidirectional instab
(Warby, Pizzari, Ford, Hahne, & Watson, 2015) (Longo et al., 2015)

5. problems with interpreting research
Hx of trauma are more likely to have a structural lesion – BUT define trauma
Pts with a structural lesion have better outcomes after Sx
In studies:
• Don’t differentiate subjects who had trauma with those with no trauma
• no imaging to rule out a structural lesion
• Studies not define level of trauma
• Therefore, studies include subjects with MDI who also have also co-pathology
in sh
(Warby, Pizzari, Ford, Hahne, & Watson, 2015) (Longo et al., 2015)
Will influence outcomes

6. problems with interpreting research
Outcome measures (OM) – scoring not specific to this condition.(CONSTANT/ASES/ROWE etc )
OM used
• 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
(Warby, Pizzari, Ford, Hahne, & Watson, 2015) (Longo et al., 2015)

7. problems with interpreting research
Interventions:
• When comparing to conservative to Sx intervention – Variation in Sx done within
same study studies.
• When in reality outcomes will differ according to type of surgery done…. not 1
homogenous group in Sx group
(Warby, Pizzari, Ford, Hahne, & Watson, 2015) (Longo et al., 2015)

8. which one?
rehab vs Sx intervention
general consensus
initially conservative Tx –
Sx intervention when failure to rehab
Clinical reasoning needs more than that…….
Lack of quality evidence to support one intervention for MDI over another

9. Guided by current clinical
opinion
Define what are we dealing with?
What factors can be considered to influence clinical decision making?

10. Large lesion repair
Bony reconstructions
Atraumatic
Adapted from Prof L. Funk slides (slide share)
Specialist rehabilitation Rehab + /- capsular plication
• differentiating the types of instab
• guide appropriate Tx
what we are dealing with?

11. Making the consultants life happy

12. If we bear in mind the following the
triangle is useful
pros
• Accs for shifting nature of the pathology
• Pts can be positioned at or between poles
• Incorporates graduation from atraumatic to traumatic
• Incorporates graduation from m patterning to structural involvement
cons
• How do we define traumatic incident? Repetitive minor trauma on jt laxity
–structural pathologies
• ID a voluntary group – regular subluxation ?trauma or not
• Need to recognise that instability is a process involving mixed pathologies
that can change over time
I.e. still can be cloudy classification

13. polar type III -pathomechanics – drivers
challenge = find the driver
non-traumatic
sh instability
(MDI)
secondarypsychological
emotional &cognitive factors
anatomical or neural defects
acquiredor genetic
redundantanteriorcapsule
bonyand capsulolabral anatomy
mechanosensitivity
neural tissue
Motor development
poor muscle tone
poor sensoryintegration
Hyperlaxity
generalisedor
congenital syndromes
Pain
peripheral (somatic)
central sensitisation(neuropathic)
changesinsensoryandmotor cortical representation
Movementdysfunction
neuromuscularcontrol
scapulakinematics
atypical patternsof muscularactivation
Proprioceptionloss
microtrauma
No trauma but…

14. atypical patterns of M activity as the
driver
BETWEEN CONTROLS AND MDI
BUT ALSO Within the MDI group:
• Contradictory results on scapulothoracic M activity patterns
• Atypical patterns of GHJ M activity
Morris et al. (2004) (Barden et al., 2005) (Illyés et al., 2009)
(Struyf et al., 2011) (Labriola, Lee, Debski, & McMahon, 2005)

15. M behaviour as drivers
(Illyés et al., 2009)
• making generalisation about m. activation patterns in
MDI difficult
• Message is the pattern differs to controls but also
differs within this population of MDI subjects
• SO does rehab change kinematics & atypical M
pattering to normal i.e. same as controls?

16. In MDI Shs Physios
They optimise mvt
QU: are kinematics and m activation relevant
OM in MDI?
Polar type III physio?

17. (Barrett 2015)
Observe mvt strategy
functional compromise
provocative movements
Correct
mvt
strategy
assessing
the effect
on
symptoms
Redirect compensatory motor patterns to optimise stability of GHJ not necessarily
correct what we think is aberrant motion, correct what works for the Pt
prognosis with a trad rehab approach?

18. Two Tips – the how to…

19. CR=Create inter-muscular synergy by biasing m activation or inhibiting M
CR= use agonist & antagonist reciprocal relaxation
CR= cuff to centralise HOH
CR= phases –levels of same ex.
Correct movement strategy

20. Correct movement strategy - demo
CR=up the chain down the chain
CR= phases –levels of same ex i.e. seated on ball

21. pathomechanics - drivers
CNS drivers
(Warby, Pizzari, Ford, Hahne, & Watson, 2014) (Barrett, 2015)
non-traumatic
sh instability
(MDI)
secondarypsychological
emotional &cognitive factors
anatomical or neural defects
acquiredor genetic
redundantanteriorcapsule
bonyand capsulolabral anatomy
mechanosensitivity
neural tissue
Motor development
poor muscle tone
poor sensoryintegration
Hyperlaxity
generalisedor
congenital syndromes
Pain
peripheral (somatic)
central sensitisation(neuropathic)
changesinsensoryandmotor cortical representation
Movementdysfunction
neuromuscularcontrol
scapulakinematics
atypical patternsof muscularactivation
Proprioceptionloss
microtrauma

22. Growing Evidence
When compared MDI with controls
• Change in threshold corticospinal response
• Which results in ↓feedback mechanism
• And altered neural control
(Alexander CM 2007
Hundza & Zehr 2007)

23. Manifests in complex patients
Cortical re-organisation
• Anxiety and emotional regulation
• 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)

24. Use of clinical tools to detect changes in
cortical activation- altered body perception
Simple clinical assessment tools show high correlation with FMRI analysis and changes in cortical activation
Clinical assessment
tools
2 pt discrimination
4.5cm =C/ 8.5cm in MDI
Left right hand judgement
Reciprocal limitations on
tasks
developmental
milestones – prev neuro
dev
(Mosley et al, 2012, Howard et al, 2015)
Pain detection
Pain/ catastrophising scores

25. Clinicians could use these tools to ID pts not likely to
respond to trad rehab approach

26. Two Tips – the how to…

27. Mirror visual feedback - demo
Motor imagery
Visual input to increase somato-senory cortex response

28. Pooled approaches - demo
• Cross midline
• Neuro dev –rolling
• Visual target
• Tactile cues – key point pelvis
• Post cuff weight to bias
• Proximal and distal kinetic chain reinforcement
(Serino er al, 2007; Mosley et al 2008, 2009.)

29. Another consideration=Level of activity
• Poor response to non Sx management noted in young athletic populations
• Incidence of spontaneous recovery was 8.7 x higher in grp that discontinued over
head sport compared to those that continued ‘head sports
• Level of demand on Sh
• more demanding sports =negative prognostic

30. Other factors- clinical decision
making
Beyond physio assess scope: Need to include
• other members of the health professions
psychologists
Consultants/radiology
neurologists
Difficult to quantify:
• Patient decisions
• Patient compliance

31. Conclusion- factors to consider in clinical decision
making- not linear – complex interaction of factors
Prognostic predictive factors – rehab – ask ourselves
• Can we Redirect compensatory motor programs to optimise stability of GH – improvement S&S
modification testing –
• Consider what the natural progression will be: Age: Younger Pts versus older Pts (MDI usually
improves with age)
• What is level of activity & expectation e.g. overhead sports – poor prognostics to rehab alone
ID unlikely to improve with Sx & trad rehab
• Are there CNS changes that can be confirmed with clinical tools
• Is there evidence of unusual pain behavior, neurogenic pain
• Psychological factors

32. Not about one solution its about a process of
decision making that is complex, in a pt that is
complex, and tailor making the solution to the
individual pt based on sound clinical judgement

33. references
• An, Y. H., & Friedman, R. J. (2000). Multidirectionalinstability of the GHJ Jt. The OrthopedicClinics of NorthAmerica, 31(2), 275–285.
• Barden, J. M., Balyk, R., Raso, V. J., Moreau, M., & Bagnall, K. (2005).Atypical Sh M activation in multidirectionalinstability. Clinical Neurophysiology:OfficialJournal of the InternationalFederationof 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-traumaticSh 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). PhysiotherapyTx for atraumatic recurrent Sh instability:early results of a specific exercise protocol using pathology-specificoutcome 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 Journalof Bone & Jt Sx. AmericanVolume,74(6), 890–896.
• Illyés, Á., Kiss, J., & Kiss, R. M. (2009). Electromyographicanalysis during pull, forward punch, elevation & overhead throw after conservative Tx or capsular shift at patient with multidirectionalSh Jt instability. Journalof
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-operativeTx of multidirectional Sh instability.InternationalOrthopaedics,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. Journalof Sh & ElbowSx, 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). MultidirectionalInstabilityof the Sh: A Systematic Review. Arthroscopy: The Journalof 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 instabilityof the Sh: biomechanics,clinical presentation,& Tx strategies. EuropeanJournalof 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 multidirectionalinstability 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). Intermediatebiomechanical analysis of the effect of physiotherapy only compared with capsular shift & physiotherapy in multidirectional Sh instability.Journal of Sh & Elbow
Sx / AmericanSh & 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). scapr positioning & movement in unimpaired Shs, Sh impingement syndrome, & GHJ instability. Sc&inavianJournal 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-basedmanagement versus Sx for multidirectionalinstability of the GHJ Jt: a systematic review. BritishJournal of Sports Medicine,bjsports–
2015–094970.http://doi.org/10.1136/bjsports-2015-094970
• Warner, J. J. P. (n.d.).Role of Proprioceptionin Pathoetiologyof 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