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[Physio Explained] Non-traumatic shoulder instability: what physios need to know with Anju Jaggi

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In this episode with Anju Jaggi, we discuss non-traumatic shoulder instability. We cover:

  • What predicts which patients will respond well to physiotherapy?
  • Mental health and self efficacy in this population
  • Goals of physiotherapy in individuals with this condition
  • Exercise prescription in this population
  • Realistic expectations for recovery

This episode is closely tied to Anju’s Practical she did with us. With Practicals you can see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster.

👉🏻 Watch Anju’s Practical here with our 7-day free trial: https://physio.network/practicals-jaggi

Anju has over 25 years of experience at the RNOHT, specialising in managing complex shoulder dysfunction. She is an active researcher and educator, having led clinical trials, published extensively, and lectured internationally. A former EUSSER President and BESS Council member, she is passionate about advancing shoulder rehabilitation and promoting physiotherapy worldwide.

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Our host is @James_Armstrong_Physio from Physio Network

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SPEAKER_01:

Our randomised clinical trial, which is published in the British Journal of Sports Medicine, where we double blinded, so the patients didn't know which group they were in, the physios treated them didn't, the surgeon was the only one who knew whether he did he or she had done the operation. So we compare the placebo, just a scope, versus the actual operation, and there was no clinical difference between either group at one year or with two years. So essentially, what I now articulate to patients is number one, even if we do choose to operate, it's a placebo effect. So the fact that the patients got better wasn't because of the surgery, but probably because they thought something had been done, or actually they ended up complying better with their physio because they'd had an operation.

SPEAKER_00:

Welcome to another episode of the Physio Explain podcast. Today we're joined by shoulder experts and specialist Andrew Jaggy for a focused discussion on shoulder instability, building on the brilliant case study she recently shared for Physio Network. With decades of clinical experience and in a leading role in upper limb rehabilitation, Andrew brings practical, evidence-based, informed insights that you can apply immediately in your practice. In this episode, we explore the key factors that help Andrew predict which patients will do well, how she explores exercise prescription, and why simplicity and consistency are crucial for success. If you want to dive in deeper, don't forget that Anju has also completed a full masterclass and practicals, all available on Physio Network. Links are in the show notes below. You won't want to miss this one. There is loads that you can apply directly into your clinic tomorrow. I'm James Armstrong and this is Physio Explained. Andrew, it is great to have you back on the Physio Explained podcast. Thank you so much for coming along. It's great to see you again.

SPEAKER_01:

No, absolutely a pleasure. Thank you for inviting me back.

SPEAKER_00:

Brilliant. Well, we couldn't not really, given the amount of content that you've got now on the Physio Network platform with your masterclass, assessment and management of shoulder pain in your practicals and also the case study most recently. So yeah, we kind of had to get you back on and very much wanted to as well. So today we said we're going to talk a bit about the non-traumatic instability, shoulder instability. And we were going to kick off with what helps predict those patients that will do well with physiotherapy.

SPEAKER_01:

The first thing to say is that non-traumatic instability is relatively rare. So most people deal with your traumatic injury. I think it's not as rare as we perceive it to be. I think a lot of young patients, often coming with sometimes pain symptoms, have probably got maybe also an element of instability in their shoulder. So when we think about the ones who are going to do well, I'm going to be really honest, over sort of 25 years of practice, I'd have to say it's really around the patient behaviour and the patient understanding. So if I had to give you a list of saying my clinic, who I think is going to respond well to treatment, it's really around their self-efficacy. So do they have a good understanding of the problem? Do they believe that the treatment we're going to give them is going to work? And do they feel they have the ability to be able to take on, and particularly if it's physiotherapy treatment, that is going to mean form forms of exercise, strength loading, the shoulder arc. So for me, they're going to be the winners really. We might go in to talk a little bit about some of the complex group I see. And I think the group that don't tend to respond to treatment, so they've had previous bailed physio, they may have even had previous surgery. For me, the demographic of this group, interestingly, is predominantly female. The average mean age cohort that ends up coming to our specialist services to life. So the sort of complicated group tend to be starting in adolescence, getting into their sort of 20s, and they often are having problems with lots of other joints. So the thing with the shoulder is it's painful and unstable, but it's part also to do with hypermobility spectrum disorder, other chronic pain, other joint issues. And if they have enlistamin loss or hypermobility spectrum, then they've got loads of other things that are associated with that, such as mental health disorders, bowel bladder problems. So I think for me, what I'm now seeing in the clinic, it's not the shoulder that's just the issue, it's everything else. And I think one last thing to say is for those listeners who know that I see a lot of complex group and they get referred to me, is that we are seeing some kind of correlation with mental health and emotional triggers. So we are now probably looking at some of these kind of muscle patterning instability shoulders as probably functional. And you almost wonder whether they have more of a functional movement disorder or akin to like a functional neurological disorder.

SPEAKER_00:

With that self-efficacy and that patient buy-in, how much do you think we can influence that to maybe support some individuals that we may not originally predict? Do you think we can change that and make them more likely to respond by some of our interventions initially?

SPEAKER_01:

Yes, absolutely. And I'm really pleased to say is that part of convincing them is using the evidence base, which we've obviously worked hard at Stanwall to contribute to. So when people come to my clinic, first of all, explaining the ATLogy, reassuring them. Having an MRA program is incredibly helpful. So if you're in that situation where you're seeing a patient for an opinion, they've had a lot of treatment and they're not responding, then I do think imaging is important. And as part of a multidisciplinary team, we do get an MRAth program or we asked for that to be imported over to us if the local hospital's done it. That's two things. It reassures us as a team that we haven't missed anything structurally or any other pathology that could be contributing to pain. And the second thing, therefore, then is by it provides the reassurance to the patient. In the old days, we used to do what was called a diagnostic arthroscopy. We used to take them to theatre, look inside with a camera, and essentially be able to then tell them whether there's structural problems within. MRGRAMs now are of a standard, but we don't need to do that. So I think the first thing is at a specialist level, if you're seeing fell treatments, sometimes imaging can be incredibly helpful to provide reassurance. But also now we we have good evidence to say that in the group that weren't responding to physio with non-traumatic instability, there was the option of surgery. So a capsia shift, which essentially is a kind of a tuck, anchors into the capsia labrum and just to literally reduce some of the volume. But our randomized clinical trial, which is published in the British Journal of Sports Medicine, where we double blinded, so the patients didn't know which group they were in, the physios treated them didn't, the surgeon was the only one who knew whether he did be or she had done the operation. So we compared a placebo, just a scope versus the actual operation, and there was no clinical difference between either group at one year or two years. So essentially what I now articulate to patients is number one, even if we do choose to operate, it's a placebo effect. So the fact that the patients got better wasn't because of the surgery, but probably because they thought something had been done, or actually they ended up complying better with their physio because they'd had an operation. The other thing we share now with patients, because we've got long-term follow-up of people having had physio and surgery, is that there seems to be a high failure rate for surgical intervention. So just under 40% of patients start to come back in about two years complaining of instability and pain again. So when you're in a clinic, I think first of all, reassurance explaining why the shoulder may be popping in and out, and that it's essentially due to muscular imbalances, control, laxity of the shoulder. They don't need to be worrying about anything broken, damaged, torn, and that can be then reassured true imaging. And then the evidence being very clear to patients now and showing that as a consensus of experts, we would not advocate surgery partly because of high risk of failure, the fact that we think it's probably a placebo intervention. But number two, there's always a risk in young adolescent shoulders that if we go in and operate on essentially what looks normal, we could end up causing more problems in terms of secondary degenerative joint changes and stiffness down the line. And I think when you lay it down like that, most patients do accept that and are actually very grateful for that level of evidence and certainty. The only other thing I I think we should probably add in here, because we did start touching upon the kind of what I call the resistant group, a group who probably do end up at Stanmore, despite having perhaps very good strength programmes, perhaps even adopting the Derby instability protocol, which I've alluded to in my case study and also in the master classes. But there are a group that still don't get better. Actually, I'd also advise people to accept that there are sometimes things that just can't get fixed. And I want to reassure people that we see the role and actually Pedia C. Stanwall is the centre to send these, but also to articulate that we're not necessarily fixing these people, but helping people to move to a level of acceptance. So a lot of our programmes now and a lot of our therapy input is more around managing chronic system instability and pain. So also remember that instability of the shoulder has lots of parallels with persistent pain as well. So the approach is very similar. It's much more than taking people through a behaviour change model, accepting it, teaching them strategies to help self-relocate the shoulder, avoid AE visits, decatastrophise, demedicalise, help with tips around functionality. So very much a kind of how to pace, how to plan, how to self-manage your ADLs with instability. So don't be under any illusion that we're still fixing these people. For many, sometimes the instability persists, but their quality of life and their now perception has changed, and therefore they actually feel that their patient-reported outcomes improve as a result.

SPEAKER_00:

Want an easier way to improve your assessment and treatment skills? Introducing practicals, where you can watch video recordings showing exactly how top experts assess and treat a range of conditions. It's the fastest way to develop your practical skills and enhance your clinical reasoning. Treat your patients like the experts do with practicals by Physio Network. Click the link in the show notes to try it for free today. So, Andrew, as you said there, you talked about exercise prescription. Any tips for listeners in terms of deciding what that prescription might be and what the best exercises might look like?

SPEAKER_01:

Keep it simple. So the first sort of headliner for me really is if somebody is testing weak, and that can be a combination of just lack of ability to move through a range, lack of an ability to move through a range but with external load, and then obviously the lack of the ability to be able to do stamina endurance. Okay, so if there's a very obvious strength imbalance or weakness, then just get whatever is weak strong. Okay, that's simple. It doesn't even have to be overly fancy exercises. If it's weakness on rotation, whether you give them resisted band by their side or walk above, put demand through those muscles and get them challenging the system. And the other tip I would say is that essentially if the shoulder is weak, target the shoulder. So in those situations, you might actually want to be doing much more targeted loading exercises which are very shoulder specific. And bringing in the kinetic chain is incredibly helpful. But in that instance, actually, if you bring in quite a lot of kinetic chain work, you might sometimes be having more of a deloading effect on the shoulder. So just keep in mind if the shoulder is weak, strengthen at the shoulder guidle. But we'll come on to talk a bit about potato cuff, the kinetic chain when we talk a more global sense around things like fear and avoidance. So I think in a simple context, we know that strengthening muscles up will improve. The Derby program is very good at taking you through that sequentially, working on both open exercises which strengthen deltoid, strengthen cuff, as well as weight-bearing exercises that help strengthen core and also shoulder blade control. So strengthening up in a simple sense. Keep it simple to no more than two exercises, two or three. And I would say now with some of the strength conditioning information we've got is pushed through to fatigue and to putting on quite a lot of demand onto that shoulder. So I've even found like sometimes even just doing maximum voluntary contractions in a nice symmetric fashion, but just pushing as hard as you can and doing low-level amounts, but pushing at maximum capacity can actually be really, really helpful. Also, don't forget, actually, grip work is really good. So we know that the strength of grip correlates with shoulder strength. So anything that works on helping with grip and also that brings in functionality as well and starts to give you a bit of that feed forward element to the brain in terms of getting your shoulder functioning in that more sort of day-to-day activity. When we start talking a little bit more about complexity of the sense of people being scared, apprehensive, of course, you know, you're worried about your shoulder maybe coming out or slipping. Then I think you need to start bespoking the exercises a lot more to bringing in functional use, so reaching activities. That's where kinetic chain can be really helpful. The things where we've tried to get someone to step or squat as they reach. Now, part of that could be distraction, then now focusing on a more complex movement pattern. Part of it could also be is that actually by bringing in kinetic chain, it's improving general core posture, position of shoulder girdle. So distraction techniques. We now find actually that even just patting a balloon, you know, in the air, bouncing a ball towards a wall. So don't just necessarily think that those ballistic fast exercises necessarily have to be done in later stages. There's some patients actually doing a very distractive task such as that helps a motor strategy come into play without the brain overthinking that it's thinking about instability. I often say to patients is that the challenge is you're aware you have a problem. So when someone asks you to do something directed at your shoulder, you're already preempting the movement pattern. Whereas if I ask you to do something more instinctive, then actually you start to gain the confidence. This is where symptom modification we know is used clinically. So things like getting people to shrug their shoulder, reaching forwards, pushing outwards, reaching forwards. Again, they can be a really nice way in to think that that can actually be utilized in an exercise prescription. So I think using ways of modifying movement, gaining confidence is an excellent way of also helping to prescribe what to do. Yeah, those are kind of the steps. I think load the shoulder when it's weak, expose it to positions of instability and apprehension to reduce fear, bring in the hand and bring in functionality because it really helps with proprioception, speed forward, and strengthen the core and bring in the kinetic chain because that will also help global strength and power, but also it will help with distractive and works very well with people with a more functional movement strategy. Interestingly, as I'm talking to you, I think you'll see a real shift towards where we were perhaps 15 years ago, where we focus very much on patterning, abnormal tone of muscles. And I think now our understanding is that yes, muscles are discoordinating and the scapula may be dyskinetic, but the drivers for that can be multifactorial. Yeah. So it's not just about focusing into the muscle and it's being overactive or underactive, but really more about how do you get the patient to move in a better way with confidence, with reduced fear, bring in strength, because that might be a reason why they're compensating. So that's where your clinical reasoning comes into play, really.

SPEAKER_00:

Brilliant. Thanks, Andrew. So I mean, time's gone so quickly already. Just briefly before we finish, you talk about sort of keeping it simple. And you uh I know in the the notes you made before this, you talked about keeping it consistent. Is there anything you want to touch on before we we finish?

SPEAKER_01:

Yeah, I think the other thing is that from the evidence base, it does appear that you do need to consistently perform exercises for probably a minimum of 12 weeks and anything up to 16. So that is the other thing I think to say to patients. Use the analogy a bit like the couch to 5K, that in order for you to really develop that movement strategy, that muscle memory, and improvements in the strength, there has to be consistency towards this. So, actually, rather than chopping and changing exercises too much, what might be more important is actually being consistent with exercise week to week. So that whole philosophy we now use about trying to introduce some form of loading and strength training for up to 30, 40 minutes twice within a week. So I think one of the key messages I'm now saying to patients is it's actually maintaining levels of exercise consistently for a period of time. And this isn't going to be doing it for two or three sessions, and then you can kind of let it go. And that's where probably the follow-up of care is more motivational and coaching rather than you feeling that you've necessarily got to change exercises. Now, for some people, you might want to progress them or they get bored and they want variety. But it's actually also okay that if they're doing those well and they're improving on them, keeping them consistent. So keep it simple, keep it consistent. And the evidence base at the moment for type 2a traumatic instability is that a minimum course of strength training for about four months tends to give you good um outcome.

SPEAKER_00:

Wonderful. Andrew, thank you so, so much for your time. It's been brilliant, and I'm sure I really sort of push listeners to check out the masterclasses, the practicals that you've done, and the case study as well that you've mentioned there, which listeners can all find in the show notes below. So, Andrew, thank you so much again for your time. I'm sure there will be another episode coming along soon where we get you back on because it's always really useful for our listeners when you do.

SPEAKER_01:

Great. Thank you very much.