Exercise based management for atraumatic instability of the shoulder in circus arts performers

Exercise-based rehabilitation for circus arts performers with atraumatic instability of the shoulder: a longitudinal prospective cohort study with quasi experimental design. Why/Rationale: Clinically diagnosed atraumatic instability of the shoulder involves symptomatic instability (aberrant humeral head movement) in at least 1 direction, accompanied by shoulder discomfort, pain, apprehension or guarding. This is a common presentation to the medical team at the National Institute of Circus Arts. The projects aim is to determine the effects of a rehabilitation exercise program on pain, strength and function in circus artists with clinically diagnosed atraumatic instability of the shoulder. What: The rehabilitation program is primarily based around maintaining good scapula and humeral head control through all ranges of shoulder motion. It is reported to be more effective than standard physiotherapy in people with multi-directional instability of the shoulder (Warby et al., 2018) but has not been tested in people with all types of atraumatic instability (uni-directional and multi-directional), or in circus arts performers. Warby, S. A., Ford, J. J., Hahne, A. J., Watson, L., Balster, S., Lenssen, R., & Pizzari, T. (2018). Comparison of 2 Exercise Rehabilitation Programs for Multidirectional Instability of the Glenohumeral Joint: A Randomized Controlled Trial. American Journal of Sports Medicine, 46(1), 87-97. doi:10.1177/0363546517734508 Materials: Participants will be provided with the necessary equipment (dumbells, rubber bands/Theratubing) to perform the intervention exercise-based rehabilitation program. Procedures: The rehabilitation exercise program is identical to the Watson Protcol presented in the trial registered ACTRN12613001240730. This rehabilitation program will be performed for 12-weeks at home and during already timetabled rehabilitation sessions within the National Institute of Circus Arts scheduled rehabilitation sessions (currently scheduled into their curriculum). The program has previously been published: Watson, L., Warby, S., Balster, S., Lenssen, R., & Pizzari, T. (2016). The treatment of multidirectional instability of the shoulder with a rehabilitation program: Part 1. Shoulder Elbow, 8(4), 271-278. doi:10.1177/1758573216652086 Watson, L., Warby, S., Balster, S., Lenssen, R., & Pizzari, T. (2017). The treatment of multidirectional instability of the shoulder with a rehabilitation programme: Part 2. Shoulder Elbow, 9(1), 46-53. doi:10.1177/1758573216652087 A summary of the stages of the exercise program are as follows (can also be seen under ACTRN12613001240730): Stage 1- Coronel Plane Strengthening 0 to 45 degrees Abduction: Scapula upward rotation and tilting Internal Rotation/External Rotation from 0 to 45 abduction with theraband Standing/bent over rows 0 to 45 degrees abduction Stage 2- Building Posterior Musculature Bent over rows Side lie external rotation Standing rows Stage 3: Flexion Drills Flexion Drills from 0 to 45 degrees Abduction Stage 4: Coronal Plane Strengthening 45 to 90 degrees Abduction Internal Rotation/External Rotation from 45 to 90 degrees abduction with theraband Standing/bent over rows 0 to 45 degrees abduction Flexion to 90 degrees abduction Stage 5: Specific Strength Drills Bent over rows (Posterior deltoid) Supine and sitting flexion (Anterior deltoid) Lateral Raises (Middle deltoid) Stage 6: Sports Specific and Functional Specific Drills Drills determined by the requirements of the patient. Load and progressed to allow for return to sport or function. Provision of services: Physiotherapists with >5 years clinical experience and trained in the protocol will be prescribing the intervention exercise program. How: Participants will have one physiotherapist session each week to assess their shoulder and progress their rehabilitation program as appropriate for their shoulder condition. The trial physiotherapists will ensure that participants can perform these exercises correctly and then they will be asked to perform them at home and in the National Institute of Circus Arts gymnasium during their scheduled rehabilitation exercise sessions (normal part of the student curriculum). Standard protocol at NICA is for a physiotherapist to be present during these timetabled exercise sessions, so this will ensure correct exercise technique is performed. Where: Physiotherapy appointments will occur at the National Institute of Circus Arts, Melbourne, Australia. When and how much: The exercise program will incorporate between 3 and 7 exercises to strengthen the muscles around the shoulder and shoulder blade, using rubber bands (Theratubing) and weights. The exercise program will take between 15 and 20 minutes to complete and will be performed two to three times a day (muscle recruitment exercises); to once every two days (muscle strength exercises), depending on the phase of the program. Adherence: Adherence will be measured through a participant exercise diary. This will be assessed each week at the physiotherapy appointment, but also formally at the 6-week and 12-week follow up post commencement of the intervention. At each physiotherapy treatment appointment, the physiotherapist will encourage the participant to adhere to the exercise protocol. Tailoring: The program will be personalised to the individual and only progressed according to the weekly assessment during the physiotherapy session.