Rehabilita)on a-er anterior stabilisa)on surgery. It s all about communica)on Jo Gibson MCSP MSc.

Transcription

1 Rehabilita)on a-er anterior stabilisa)on surgery It s all about communica)on Jo Gibson MCSP MSc.

2 Today Considera)ons - ge;ng it right at the start Pre- op Assessment What I need to know Safe zone Role of early mobilisa)on

3 Considera)ons Sub- op)mal outcomes are related to:! Propriocep)on Link with no. disloca)ons & length of Sx Link to loss ER / IR in neutral Movement panern Laxity Stein et al 2011, Ide et al 2004, Wilks et al 2006, Neri et al 2010, Louw et al 2014

4 Factors associated with dissa)sfac)on Pain S)ffness Recurrent Instability Unable to return to sport/hobby Huang et al 2015, Kim et al 2012

5 The Role of Preopera)ve Clinic? Educa)on, educa)on, educa)on! Expecta)ons Planning/pre- emp)ng? block Sugai et al 2013, Louw et al 2014, Linton 2005

6 What do I need to know? The Ingredients I have to work with? - Pa)ent factors - Impact of pathology - Surgical factors How it impacts dynamic stability?

7 What do I need to know? Pa)ent Factors Compliance Laxity Occupa)on/Sport Previous injury - kine)c chain deficits Sciascia et al 2010 Gibson 2011

8 What do I need to know? Impact of pathology History Pain Impact dynamic stabilisers Propriocep)on Cor)cal changes Warner 2002, Borsa & Fu 2006, Shitara et al 2014

9 Current Trends The Brain! Link with chronicity Recurrence Associated with dura)on vs intensity of pain Ngomo et al 2014, Heales 2013, Berth et al 2009, Conboy 2014 Howard et al 2014

10 What do I need to know? Surgical Procedure Extent damage Fixa)on - Anchor type, suture etc. Tissue quality Laxity McFarland et al, 2005 Kim et al, 2006

11 What do I need to know? Surgical Factors The Safe zone Inflamma)on

12 Safe Zone: Early Mobilisa)on Decrease pain/ swelling Maintain ROM Propriocep)on Dynamic Stability Anatomy?! None of these things are achieved keeping the arm s)ll!

13 Safe Zone: Early mobilisa)on Advantages? Enhanced Healing? Reduced Pain? Early return to func)on Pa)ent Sa)sfac)on Kim 2003

14 My Job is to avoid this!

15 My Job..is to facilitate this

16 Early Mobilisa)on: Keeping it safe SSP ISP AD AA Flex 3% 8% 11% Pend 9% 9% 3% T Bar 19% 27% 43% Uhl 2010

17 Early Mobilisa)on: Keeping it safe SSP ISP AD St Squat 4% 2% 3% Ball Roll 5% 4% 6% Kibler, Uhl 2008

18 What Are We Protec)ng? Reality Push a door or carry a load Subscapularis 29% 68% MVC Supraspinatus 10-20% MVC Infraspinatus % MVC Smith 2007 Uhl 2010

19 Phase I Protec)ve? Facilitatory Vs. Protec)ve? Safe zone it s big! Load to failure?

20 Rehabilita)on Outline Sling? Educa)on! Mobilisa)on day 2 Safe zone Anterior to scapula plane 6/52 Pain & Motor control determines progression

21 Rehab Priori)es: Dynamic Stability Propriocep)on Co- contrac)on Direc)on specific Kine)c chain Copyright ShoulderDoc McMahon & Lee 2002 Teyssedre et al 2000 Konrad et al 2006 Lewis 2005

22 Rehab Priori)es: Dynamic Stability Kine)c Chain Reduces abnormal load on the shoulder Dynamic integra)on enhances local recruitment panerns Facilitates local recruitment Sciascia 2012, Khazhadyiat et al 2013, Cools et al 2012

23 Rehab Priori)es: Dynamic Stability Is it safe? Scapula congruence Pain Muscle control Know the safe zone!

24 Rehab Priori)es: Dynamic Stability Propriocep)on Co- contrac)on Direc)on specific Kine)c chain Copyright ShoulderDoc McMahon & Lee 2002 Teyssedre et al 2000 Konrad et al 2006 Lewis 2005

25 Rehab Priori)es: Dynamic Stability Op)mal Neuromuscular Control Dynamic stabilisa)on Preparatory and reac)ve muscle ac)va)on Func)onal specificity Power /Strength Endurance McMullen 2000 Riemann 2002 Rasool 2007 Copyright ShoulderDoc

26 Rehab Priori)es: Dynamic Stability Op)mal Neuromuscular Control Dynamic stabilisa)on Preparatory and reac)ve muscle ac)va)on Func)onal specificity Power /Strength Endurance Copyright ShoulderDoc

27 Rehab Priori)es: Dynamic Stability Func)onally relevant Explosive movement EOR load Sustained eleva)on* Confidence*

28 Is it just about strength? Joint posi)on sense versus movement control Feedback motor planning Cor)cal changes Emphasis on func)onal engagement with hand important Uri et al 2015, Arzi et al 2014, Koo 2011

29 Op)mising Outcomes: Real Life? week average/8% failure rate Single surgeon series 37 professional footballers No exclusion unlike Kim! Early mobilisa)on in protected arc Key ingredients Rx

30 Op)mising Outcomes: Real Life? Av return to sport 7.5/52 quicker Players returned to play mean 9.5/52 (7.5 12) 8 % failure rate* Poor compliance VAS < 2 3/52 quicker Func)onal ROM 4-6/52 Laxity?

31 Monitoring Fa)gue over season Propriocep)on GIRD Thoracic rota)on Scapula dyskinesis Kine)c chain injury Laxity

32 Considera)ons: Not All Pa)ents Are The Same! General Popula)on Compliance Pre- op Status Func)onal Demands So- )ssue status Kine)c chain!

33 Working Together To Op)mise Pa)ent Outcomes Key principles; Communica)on Pa)ent factors Impact of pathology Surgical procedure Rehabilita)on priori)es Op)mising the biology!

34 Is there a magic protocol? ASSET protocol versus normal care? Home based programme Comparable in terms of - ROM - Return to work and sport BUT Strength, Propriocep)on,? recurrence Know key principles Damkjaer et al 2015, Ismail et al 2014

35 Postopera)ve Rehabilita)on: A Best Prac)ce Approach But.know what you are dealing with! The Individual Surgery Risks Expecta)ons

36 Its all about Teamwork &