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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 15  |  Issue : 3  |  Page : 232-236

Integrative management of recurrent anterior shoulder dislocation


AAyurvedic Physician and Physiotherapist, SGS Hospital, A Unit of Swami Narahari Teertha Medical Mission Trust, Sri Ganapathy Sachchidananda Ashram, Mysore, Karnataka, India

Date of Submission07-Oct-2020
Date of Decision23-Oct-2020
Date of Acceptance02-Nov-2020
Date of Web Publication25-Sep-2021

Correspondence Address:
Dasari Sri Lakshmi
SGS Hospital, A Unit of Swami Narahari Teertha Medical Mission Trust, Sri Ganapathy Sachchidananda Ashram, Mysore - 570 025, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joa.joa_208_20

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  Abstract 


Introduction: Shoulder joint is the most mobile ball and socket joint. It allows movement along three planes due to its bony configuration and loose joint capsule. Stability of shoulder joint mainly depends on muscle strength supporting the joint. Shoulder dislocation is common injury; anterior dislocation being most common. Main Clinical Findings and Diagnosis: 38 year male patient with a history of fourth recurrent anterior shoulder dislocation (RASD) reduced under anaesthesia was immobilized in sling for 6 weeks. After immobilization, active assisted flexion and abduction was restricted to 90° associated with pain and feeling of instability. Interventions: Integrative treatments of Ayurveda and Physiotherapy were given in three divided sessions, 7 days in each session for a total of 21 treatment days. Ayurveda treatments included Sthanika abhyanga (SA) and Shashtika shali pinda sweda (SSPS). Physiotherapy treatments included interferential therapy (IFT) and exercises. Outcome: Nourishing external treatments enhanced muscle strength and joint mobility. Conclusion: There was appreciable improvement in shoulder muscle strength, active range of motion (AROM) and no incidence of recurrence since past 2 years. The patient is able to carry out unhindered daily activities with full and free AROM.

Keywords: Abhyanga, integrative treatment, pinda sweda and interferential therapy, recurrent shoulder dislocation


How to cite this article:
Lakshmi DS. Integrative management of recurrent anterior shoulder dislocation. J Ayurveda 2021;15:232-6

How to cite this URL:
Lakshmi DS. Integrative management of recurrent anterior shoulder dislocation. J Ayurveda [serial online] 2021 [cited 2021 Oct 21];15:232-6. Available from: http://www.journayu.in/text.asp?2021/15/3/232/326709




  Introduction Top


Dislocation[1] of a joint occurs when the articular surfaces are completely separated from each other so that all apposition is lost. Some joints are more likely to dislocate than others because of their anatomical structures. This is particularly so in case of shoulder.[2] Joint capsule is loose especially on the inferior aspect to allow wide range of movements. Anterior dislocation is caused by fall on outstretched hand or by forcible external rotation and extension of the shoulder. Dislocated humerus may come in line with sub-coracoid area (common amongst anterior dislocations), sub-glenoid and sub-clavicular are rare. Complications of dislocated shoulder include an extensive damage of joint capsule, fracture of greater tuberosity or neck of humerus, and axillary nerve and axillary artery injuries.[3] Main cause for RASD is trauma, and other causes include congenital malformations, extensive muscle paralysis like in hemiplegia where there is no return of muscle power. Usually, dislocations due to trauma are accompanied by severe soft-tissue damage due to stretching or tearing of the structures around the joint. Muscles, tendons, ligaments, synovial sheaths, and cartilage may be damaged that may need surgical repair.[4] Sustained shoulder damage in violent dislocation is permanent and tends to occur with increasing frequency and with decreasing violence.[1] Physiotherapy will be given after reduction and immobilization to rehabilitate the shoulder muscles and strengthen them.

As this is a recurrent case of shoulder dislocation, Sthanika abhyanga (SA)[5] and Shashtika shali pinda sweda (SSPS)[6] were given to strengthen the muscles and interferential therapy (IFT) to help improve active range of motion (ROM).[7] These modalities of treatments helped in obtaining cumulative effect of integrative system.[8],[9] In both the systems, only external modalities were opted to strengthen the shoulder muscles, improve joint ROM, and reduce chances of recurrence.


  Case Report Top


A 38-year-old male janitor with a history of fall on outstretched right hand had fourth reoccurrence of anterior shoulder dislocated. Reduction was done under anesthesia followed by immobilization for 6 weeks. There were no other complications associated in all the past four episodes of recurrent anterior shoulder dislocation (RASD).

On examination

Shoulder joint active-assisted movements were restricted to 90°, and all ROMs were measured using goniometer. Flexion by clasping both hands together and abduction by wall climbing were restricted due to pain and feeling of joint instability above 90°. To avoid mildest triggering factors that may precipitate RASD, passive ROM could not be evaluated. In this case of RASD, muscle weakness was the prime cause and the patient also developed shoulder stiffness.

History

The patient had earlier episodes of RASD thrice in 15 months of duration. After the fourth episode, the patient complained of joint instability and continuous pain in the right shoulder and arm area. Hence, the patient was unable to carry out daily activities and approached the Department of Physiotherapy, SGS Hospital, for treatment.

Aims and objectives of the study

  • Muscle strengthening
  • Full and free active ROM
  • Prevention of RASD for maximum duration
  • Carry out unhindered daily activities.


Procedures administered to the patient

The weaker scapular and arm muscles that bring about shoulder joint movements were treated with SA and SSPS.[8],[9] To reduce shoulder stiffness, IFT was given for analgesic effect.[7] Patient was treated for 21 days, divided into 3 sessions, with duration of 7 days as one session. Bahyopakrama was done for one week followed by 3 weeks of gap period. Details are described in [Table 1] and [Figure 1].[10],[11],[12]
Table 1: Procedures of integrative treatments in recurrent anterior shoulder dislocation

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Figure 1: Before and after integrative treatments

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  Results Top


After the first session of treatment, pain was reduced to a great extent, evaluated by verbal rating scale. Henceforth, active and active-assisted exercises were encouraged to improve active joint mobility. Gap period of 3 weeks was continued with shoulder exercises. After the second session of treatment, the patient was able to perform overhead movements with one KG dumbbell though rotation was not full and free in final ranges. Third session was done as a preventive measure for recurrence. Integrative treatment results are explained in [Table 2].
Table 2: Results of integrative treatments in recurrent anterior shoulder dislocation

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  Discussion Top


Anterior dislocation is the most common among shoulder dislocations.[1] Recurrence of dislocation indicates weak muscles. Hence, in this case, treatment aims at muscle strengthening, full and free active ROM, and prevention of RASD for maximum duration to carry out unhindered daily activities. According to Ayurveda, this case can be categorized as Abhighatajanya (traumatic origin) apatarpana vyadhi[10],[11] (disease leading to depriving) where Mamsa dhatu (muscles emaciation/wasting) was observed. Dosha vitiated is Vata due to the impact of Abhighata. Hence, Bruhmana (nourishing) therapy was the choice of treatment[10],[11] in this case to combat weakness of the right shoulder joint muscles caused due to Ksheena guna of vitiated Vata dosha. Hence, Santarpana and Vatahara line of treatments were adopted to improve Ksheena tava of Mamsa dhatu and Vata dosha.

Equal quantity of Bala mula taila[12] and Maha masha taila[13] was used for SA since they have Santarpana gunas and are indicated for Balya (nourishing) and Vatahara actions. Abhyanga[14] mitigates Vata, Pushtikara (promotes strength), and Bhruhatwakrit (stoutening). Ksheera[15] has Guru, Snigdha gunas and acts as Balya, Jeevaniya, Rasayana, Vrishya, and Medhya. Shastikashali[6] (rice harvested in 60 days) is the best among Shali as it has Balya, Varnya, and Tridoshahara properties. Ashwagandha churna[16] and Bala churna[17] have Guru, Snigdha, and Pichchila properties, with Balya and Vatahara actions. Ashwagandha churna and Bala churna were processed with Ksheera to improve muscle bulk and strength. Shastikashali was cooked very soft and Pottali was prepared. SSPS was performed with above Ksheerayukta churnas as medium. Considering the Dosha and Dhatu involvement, SA and SSPS were performed in Anuloma gati (downward/away from body) as mentioned in classics for Vata niyantrana. All Dravyas used in SA and SSPS are Santarpana in nature and Vatahara, to bring about the cumulative effect in improving the condition.

On physical therapy, all treatment modalities are given externally to maintain physical health. IFT was given following the Ayurvedic treatment to facilitate joint mobility. IFT has its mode of action on reducing edema and inflammation and analgesic effect by pain gate theory. Integrative effects of these three treatments cumulatively helped to improve muscle tone, strength, and release joint stiffness. As this is a RASD case, only active-assisted and active exercises were encouraged after 5 days of Ayurveda treatment. Active-assisted exercises were done with the support of equipment such as shoulder pulley, shoulder wheel, or wall climbing. Five days of Bahyopakramas helped to regain muscle strength, and the warmth during the treatment would help improve local blood supply. Combination of short-wave diathermy (SWD) and IFT would help in improving local blood supply and reducing inflammation, followed by exercises. However, SA and SSPS help gaining muscle strength too along with the benefits of SWD treatment. Hence, integration of systems was opted rather than only physiotherapy.

After 5 days of integrative treatment, rehabilitation or strengthening exercise program was commenced. After 1 week of treatment, active-assisted exercises were continued, and after 3 weeks of gap period, the next treatment session was commenced. Exercise therapy in the gap period helps to retain muscle strength gained from Ayurveda treatments and facilitated joint mobility. In the gap period, rehabilitation of hand muscles to carry out daily activities is encouraged, as ultimate utility of integrated approach is unhindered daily activities and recurrence. By the end of the second session treatment, active ROM was full and free except for rotations. Third session treatments were done with the intension of further strengthening to prevent further recurrence. Hence, only active exercises were encouraged to improve strength. The patient was able to exercise with 1 kg dumbbell including rotations.

Santarpana bahyopakramas were selected as the treatment for this case so that the route of administration is external in both the systems of medicine to enhance the cumulative effects.[7],[8] These treatments facilitated faster recovery of RASD by strengthening shoulder girdle muscles to carry out unhindered daily activities of life. Shoulder dislocation did not recur for the past 1½ years in this case. Any uncomplicated RASD may improve positively as this case did. However, continuation of integrative treatments at a frequency of two sessions in a year may help patient to prevent RASD and can be topic of research for the preventive management of RASD, by conducting in more number of patients.


  Conclusion Top


RASD treated with integrative approach helped strengthening of shoulder muscles and obtaining full and free active ROM. Integrative treatment in RASD proved beneficial and prevented recurrence in the past 1½ years. Noncomplicated RASD may be attempted with such treatments for appreciable results. Continuation of integrative treatment helps maintain muscle power and thus may prevent recurrence of dislocation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.





 
  References Top

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3.
Thomson A, Skinner A, Piercy J. Dislocations. In: Tidy's Physiotherapy. Ch. 5., 12th ed. Mumbai: Varghese Publishing House; 1996. p. 34-5.  Back to cited text no. 3
    
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Srilakshmi D, Chaganti S. A holistic approach to the management of Erb's palsy. J Ayurveda Integr Med 2013;4:237-40.  Back to cited text no. 8
[PUBMED]  [Full text]  
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Dasari SL. Integrative rehabilitation of post Open reduction internal fixation [ORIF] scapular body and glenoid fracture A single case study. Int J AYUSH CaRe 2020;4:21-8.  Back to cited text no. 9
    
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Mishra LC, Singh BB, Dagenais S. Scientific basis for the therapeutic use of Withania somnifera (ashwagandha): A review. Altern Med Rev 2000;5:334-46.  Back to cited text no. 16
    
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    Figures

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    Tables

  [Table 1], [Table 2]



 

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