Shoulder Pain Clinical Trial
Official title:
The Effectiveness of Overhead Perturbation Training on Joint Position Sense in Patients With Functional Shoulder Instability: A Pilot Study With Blinded, Randomized Controlled Trial Design
The purpose of the trial is investigate the benefits of a novel, newly invented exercise
technique protocol relative to physiological changes in upper limb proprioception (primary)
and subjective readiness for return to sport (secondary).
The intervention (Overhead perturbation training) will be compared with a control
intervention (non-perturbed stimulus) in a population of type II anterior glenohumeral joint
instability patients (according to the Stanmore classification of instability). Each group
will be assessed at baseline for glenohumeral joint proprioception (via lazer-pointer active
relocation test), as well as perceived functional level (via Western Ontario Shoulder
Instability index) and Shoulder Instability‑Return to Sport after Injury (SIRSI) score. They
will then undertake a 6 week exercise regime which is exactly the same- except the
intervention used perturbated stimulus and the control uses non-perturbed stimulus. Outcome
measures are re-assessed at the end of the intervention period. Results will be assessed
statistically for statistical significance.
Overhead athletic performance requires both static and dynamic mechanisms to coordinate
glenohumeral and scapulothoracic stability to induce the appropriate motor response. Active
function is predicated on a sufficient balance of muscular strength, endurance, flexibility
and neuromuscular response to proprioceptive input. Coordinating, planning and synthesising
complex multi-joint information is a process within the central nervous system, from the
periphery to the higher centres of the brain, in a synergy of afferent and efferent feedback.
Joint position sense plays an important role for the shoulder joint in two key components of
athletic performance: conscious limb placement and unconscious motor patterning in response
to external force during movement. Such motor patterns can be characterised as the motor
responsiveness to perturbations of joint position. This assists efficiency of muscular
coordination when the shoulder is placed in the long lever position during overhead
activities, where the desired motor pattern reaction is essential alongside contractile
strength for successful performance and attenuation of injury risk. It is suggested that
efficiency in neuromuscular control to provide responsive stabilization is necessary to
sustain high levels of overhead performance and to avoid injury. The neuromuscular control
response of the shoulder musculature on glenohumeral and scapulothoracic joint positions
becomes deficient in the presence of structural injury. For example, rotator cuff injury
specifically leads to deficiencies in neuromuscular control timing, patterning and strength
compared with asymptomatic clients.
Perturbation of upper limb position during overhead activities causes unpredicted change in
tissue length, resulting in a responsive pattern of muscular contractions. The OPT exercise
series ensures that the deficient client is exposed to positions of vulnerability against
displacement of the limb by external force. It is postulated that neural adaptations are
induced through introduction of both rhythmic and sudden alterations to these positions A
training stimulus (such as OPT) which facilitates neuromuscular control and speed of response
to perturbation has potential to enhance overhead function. This signifies the role of
neuromuscular control training in both rehabilitation and prevention of shoulder joint
injury. The inclusion of this type of exercise training during rehabilitation and as part of
injury risk minimisation strategies is an important component to sustain synchronization of
muscular movement patterns.
Population in Focus
The subjects recruited for this study will be explained in greater depth further in the
proposal, however are characterised by having a degree of functional glenohumeral joint
instability. The physiotherapy class setting which will be utilised as the source of
referrals is a heterogenous group of upper limb disorder patients, with a distinct sub group
of individuals with functional instability who achieve sufficient recovery to meet the
criteria for return to sport. According to the Stanmore classification of shoulder
instability this group would correspond to Polar type II-III- that is placed on a continuum
between atraumatic structural instability and non-structural, muscle patterning instability.
Current treatment versus OPT
The optimal management of anterior shoulder instability in those who undertake sport
continues to be a challenge. Exercise therapy rehabilitation in a structured protocol shows
statistically significant changes in validated outcome measures (Oxford Instability Shoulder
Scores and Western Ontario Shoulder Index scores) but fails to incorporate exercise at the
point of most instability through range of motion, particularly with sufficient challenge to
the neuromuscular system to promote adaptation against perturbation at this point.
Of course OPT is not suggested to replace traditional measures of exercise therapy, but
instead is designed to complement and optimise rehabilitation. By influencing both the
physical and psychometric obstructions to return to activity, the OPT aims to improve patient
care and enhance quality of life in its users. This has the additional benefit of
streamlining the care pathway of this patient population, and in preparing them to return to
higher levels of function, will potentially reduce recurrence of future injury. The pathway
for these patients is optimised and made more efficient by providing the same amount of
therapist contact, in a class setting to incorporate multiple users at once, but should
enhance post intervention clinical scores. The application of similar programmes as a
component of rehabilitation is already considered elsewhere; however the specific nature of
OPT is suggested to enhance even these currently used protocols.
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