J Shoulder Elbow Surg (2014) 23, 355-360
www.elsevier.com/locate/ymse
Sensorimotor control deficiency in recurrent anterior
shoulder instability assessed with a stabilometric
force platform
Pascal Edouard, MD, PhDa,b,c,*, David Gasq, MD, MScd, Paul Calmels, MD, PhDb,c,
Francis Degache, PhDe
a
Department of Clinical and Exercise Physiology, Sports Medicine Unit, University Hospital of Saint-Etienne, Faculty of
Medicine, Saint-Etienne, France
b
Laboratory of Exercise Physiology (LPE EA 4338), University of Lyon, Saint-Etienne, France
c
Department of Physical Medicine and Rehabilitation, University Hospital of Saint-Etienne, Saint-Etienne, France
d
Department of Functional Physiology Explorations, University Hospital of Toulouse-Rangueil, Toulouse, France
e
School of Health Sciences, Health Research Unit, University of Applied Sciences Western Switzerland, Lausanne,
Switzerland
Background: Deficiencies in both afferent proprioceptive information and efferent motor responses
have been independently reported in patients with recurrent anterior shoulder instability. We used a vali-
dated force platform method to analyze the association between the stabilometric parameters of the
upper limb as representative of the shoulder’s sensorimotor control and clinical glenohumeral joint
instability.
Methods: We enrolled 32 patients with unilateral recurrent anterior post-traumatic shoulder disloca-
tion, on the dominant side in 13 patients (DIG) and the non-dominant side in 19 patients (NDIG)
and 16 healthy nonathletic subjects (CG). Displacements of the Center of Pressure were measured by
a Win-Posturoâ Medicapteurs force platform in the upper limb weight-bearing position with the lower
limbs resting on a table up to the anterior superior iliac spines. The association between stabilometric
values and clinical shoulder instability was analyzed by side-to-side comparisons and comparisons to
a control group.
Results: For CG and NDIG, there were no side-to-side differences. For DIG, stabilometric values were
significantly higher on the dominant pathological shoulder side than on the healthy contralateral non-
dominant side (P < .01). The percentage of side-to-side differences was higher in DIG than CG
(P < .01).
Conclusion: Sensorimotor control deficiency was associated with recurrent anterior shoulder in-
stability, especially in patients with the pathological shoulder on their dominant side. Using
a force platform to assess sensorimotor control of the shoulder is feasible in patients with shoulder
instability, and can allow assessment of the global sensorimotor control deficiency present in unstable
shoulders.
This study was exempt from IRB Ethical Committee approval. University Hospital of Saint-Etienne, F-42055 Saint-Etienne Cedex 2,
*Reprint requests: Pascal Edouard, MD, PhD, Department of Clinical France.
and Exercise Physiology, Sports Medicine Unit, Bellevue Hospital, E-mail address: [email protected] (P. Edouard).
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees.
http://dx.doi.org/10.1016/j.jse.2013.06.005
356 P. Edouard et al.
Level of evidence: Basic Science Study, Kinesiology.
Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Stabilometry; center of pressure; metrology; neuromuscular control; shoulder assessment;
shoulder instability; dislocation
The glenohumeral joint is the most mobile, but also the It has been suggested that shoulder proprioception,
most frequently dislocated articulation in the human body.3 muscle coactivation and joint stability are promoted by
Anterior dislocation caused by trauma is by far the most close kinetic chain exercises using an upper limb weight-
common diagnosis of shoulder dislocation. The recurrence of bearing position11,13,22,24 and that the sensorimotor control
dislocation is frequent, especially in athletic patients 15- of lower limbs can be assessed by postural control analysis
30 years of age (50-90%), which can lead to incapacity using a force platform.1 Following these ideas, Edouard
or handicap in professional, social, sporting and/or daily life.3 et al6 suggested that using a force platform to assess
Its precarious stability is ensured by a delicate relationship shoulder sensorimotor control would be both feasible and
and fine balance between static and dynamic stabi- reliable. This assessment procedure has been validated in
lizers.3,5,11,12,17,24 Moreover, the sensorimotor system plays an a homogenous population of healthy subjects. A force
integrative role by mediating these static and dynamic stabi- platform provides the opportunity to monitor the displace-
lizers.11-13 Sensory or proprioceptive information (afferent) ments of the center of pressure (CoP) which incorporate
from the mechanoreceptors present in the static (especially corrective muscular actions.16 Any deficiency of the
capsuloligamentous) and dynamic (musculotendinous) struc- sensorimotor system (eg, ligamentous and capsular defi-
tures travels to the central nervous system where it is integrated ciency [afferent], central inhibitions [central]), strength or
to elicit the necessary neuromuscular control (efferent motor coactivation (efferent) in patients with glenohumeral joint
responses) that allows shoulder stability and coordinated instability could be highlighted by some variations of CoP.
movement patterns.11-13,15 Precise sensorimotor system Our hypothesis was that there is an increase of CoP
function is necessary for effective motor program develop- displacements.
ment and to optimize the constant feedback-adjustment Using this validated force platform process method we
interplay required during complex motion, especially in proposed to analyze the association between shoulder
order to maintain the humeral head permanently centered in sensorimotor control and glenohumeral joint instability in
the scapular glenoid. Glenohumeral recurrent anterior insta- recurrent anterior instability on nonoperated patients.
bility typically occurs with deficiencies in bony, soft tissue
(capsuloligamentous) or the dynamic muscular restraint that
prevents translation of the humeral head on the glenoid.3,5,25
Recurrent anterior instability can also occur in cases of
Materials and methods
a deficiency in the sensorimotor system.
Deficiencies in both the afferent proprioceptive infor- Population
mation and efferent motor responses have been reported in
Two groups were constituted for this observational controlled
patients with recurrent anterior glenohumeral instability.
study. Patients with recurrent anterior post-traumatic gleno-
Several studies have reported proprioceptive deficits in
humeral instability (patient group ¼ RAIG) were selected
patients with recurrent anterior instability regarding both prospectively and consecutively from a physical medicine and
the joint position sense and kinesthesia.8,17,18,25 Accom- rehabilitation outpatient unit (from 2010 to 2011) together with
panying the disruption of the static stabilizing structures, a matched control group of nonathletic healthy subjects (control
damage to the capsuloligamentous structures could lead to group ¼ CG).
proprioceptive deficits by decreasing mechanoreceptor Inclusion criteria for the RAIG were as follow: patients with
stimulation as a result of tissue deafferentation and/or symptomatic recurrent unidirectional anterior glenohumeral
increased tissue laxity.13,18 Neuromuscular control deficits dislocation, with post-traumatic onset, scheduled for stabilizing
have also been reported in patients with recurrent anterior surgery with a healthy, stable contralateral shoulder, no associ-
instability who presented muscle weakness in the ated injury (rotator cuff injury or bone injury with the exception
of Hill-Sachs lesions or bony Bankart lesions on computer
shoulder4,5,17,21,23 and/or alterations in their coordinated
tomographic [CT] arthrography), no prior participation in upper-
muscle activation patterns.7,9,10 These results suggest that
limb sports such as those involving throwing or swimming, and
sensorimotor deficiencies are associated with recurrent no contraindications to isokinetic testing.2 Patients with volun-
anterior instability. However, to our knowledge, no data are tary instability, rotator cuff disease, neurological disorders,
available for global shoulder sensorimotor assessment in musculoskeletal injury or pain, and/or a history of back, wrist
patients with recurrent anterior instability because there and/or elbow pain, were excluded. The diagnoses of shoulder
was no method available to do this satisfactorily. instability were established by the same surgeon (non-author)
Sensorimotor deficiency in shoulder instability 357
after medical and physical examination and following the
accepted recommendations.3
The CG participants were all members of the hospital staff.
They were recruited in order to perfectly match the RAIG, so that
shoulder instability remained the only variable between the 2
groups. Indeed, apart from the shoulder instability, both groups
showed no other constraints on the shoulder (no strengthening,
upper-limb sports, or other shoulder abnormalities). The subjects
in the CG were voluntary participants without prior shoulder pain,
dysfunction or pathology, and who did not participate in upper-
limb sports such those involving throwing or swimming. Subjects
who reported neurological disorders, musculoskeletal injury or
pain, and/or a history of back, wrist and/or elbow pain were
excluded.
Thirty-two patients (4 females and 28 males) were included in
the RAIG. The mean age was 29.8 10.4 years (range, 15-
54 years), mean height was 175.3 7.0 cm, mean weight was Figure 1 Position 1: The subjects were in prone position with
75.6 13.7 kg, and the body mass index (BMI) was lower part of the body supported on an adjustable height table up
24.5 3.6 kg m2. Patients had experienced a mean of 3 3 to the anterior superior iliac spines and hands on the force plat-
dislocations before the assessment. The average time between the form with elbows in full extension, wrists at 90 of extension and
first dislocation and the assessment was 5 6 years. The average shoulder at 90 of elevation.6
Rowe score was 64 14 (range, 30-95). No patient underwent
rehabilitation before the study. Seventeen patients did sports not
involving the upper limbs (running, cycling, walking, skiing) at instructed to lock their wrists, elbows and shoulders during the
the time of the study. In 13 patients, the dominant side was tests and remain as still as possible. They were asked to maintain
involved and in 19, the non-dominant side. The dominant side was the head in neutral alignment with the trunk axis and to focus on
the side used for writing. The RAIG was divided into 2 groups, a fixed visual reference on the platform.
depending on whether the affected shoulder was on the dominant Stabilometric tests were performed in a noise-free environ-
(DIG) or nondominant side (NDIG). There were no morphological ment, on hard floors, and with no variation in luminosity.1 All
differences between the 2 groups, except for increased age in DIG. measurements were made by the same experimenter (P.E.) to
Sixteen subjects (2 females and 14 males) were included in the avoid inter-tester variability. The same standardized procedure
CG. The CG was matched with the study group for sex, age, was used with each subject and they were fully briefed before
weight, and height, with no significant differences between CG testing began. A 30s familiarization period with eyes open, sup-
and RAIG and/or between DIG and NDIG. The mean age was ported on both hands, preceded each test. Stabilometric measures
29.3 8.1 years, the mean height was 177.6 8.6 cm, the mean were performed in 4 conditions: eyes open supported on both
weight was 72.7 12.8 kg, and the body mass index (BMI) was hands (EO), eyes closed supported on both hands (EC), eyes open
22.9 2.2 kg m2. supported on the dominant side (DS), eyes open supported on the
non-dominant side (NS). The order of testing was always the
same: EO, EC, healthy shoulder side and pathological shoulder
Stabilometric assessment side for DIG and NDIG; and EO, EC, and random order for DS
and NS for CG. For the DS and NS conditions, the hand position
A force plate (Win-Posturoâ, Medicapteurs SA, Toulouse, on the platform was the same as for EO and EC, and the
France) and a PC computer with the Medicapteurs Winpos- contralateral hand was pressed on the patient’s abdomen. The
ture2000â software (Medicapteurs SA, Toulouse, France) were recordings started 5 seconds after the subjects maintained the test
used to measure and record the CoP displacements of the upper position and lasted for 25.6 seconds. A 30s period rest was given
limbs. The force plate had 3 pressure gauges (hysteresis <0.2%). between each condition.
Signal processing was carried out with a 16-bit A/D converter at Only 2 parameters were studied, because they had previously
40 Hz. Each test lasted 25.6 seconds. been reported as reliable6: the total length of CoP (CoP XY length,
The subjects were in the prone position with the lower part of in mm) and the mean of instantaneous CoP velocity (CoP velocity,
the body supported on an adjustable height table up to the in mm s1). These parameters reflect the net neuromuscular
anterior superior iliac spines with their hands on the force plat- activity required to maintain balance, small scores reflect greater
form (Fig 1).6 The height of the table was adjusted to allow the stability (thus better postural stability), whereas large scores
upper limbs to remain outstretched at 90 to the ground with 90 indicate less stability. For each parameter, the percentage of side-
of shoulder flexion. The 2 hands were placed on the platform to-side differences was calculated as following: (DS valueNS
according to precise landmarks with respect to the platform’s X value)/NS value. In order to determine the ability of a subject to
(frontal plane) and Y (sagittal plane) axis, with the fingers maintain his body in a stable position supported on only 1 hand,
pressed together, 4 cm between the wrists and 15 of lateral the difference between the unilateral support value and the bilat-
orientation from the sagittal plane. The wrists were at 90 eral support value (‘DS - EO differences’ and ‘NS - EO differ-
extension to place the upper limbs at 90 to the platform and the ences’) was calculated for each variable, and was called the
ground. The elbows were in full extension. Subjects were ‘unilateral stability index’.
358 P. Edouard et al.
Statistical analyses Table I Mean values of COP XY length and COP velocity, of
side-to-side differences and of ‘‘unilateral stability index’’ in
Means and standard deviations (SD) were calculated for all vari- dominant recurrent anterior instability group (DIG), in
ables. The association between stabilometric parameters and nondominant recurrent anterior instability group (NDIG) and
recurrent anterior instability was analyzed by comparisons to in control group
a control group and side-to-side comparisons. Variables were
tested for normal distribution with the Shapiro-Wilk test. As the Stabilometric variables CoP XY length CoP velocity
distribution of variables was not seen to be normal, differences in (mm) (mm s1)
stabilometric parameters between groups (DIG vs NDIG vs CG) EO
were analyzed using the Kruskal-Wallis rank sum test, and DIG 191.6 138.5z 9.2 5.3z
differences between dominant and nondominant sides in each NDIG 169.0 42.4 8.3 1.6z
group were analyzed using the Wilcoxon nonparametric test. The CG 160.6 36.6 8.3 1.4
influence of vision was analyzed in each group between EO and EC
EC values using the Wilcoxon nonparametric test. These analyses DIG 214.0 190.4z 10.2 7.4z
were made using Statviewâ software (Abacus Concepts, Berke- NDIG 178.6 50.8 8.9 1.9z
ley, CA, USA). The level of significance was fixed at P < .05. CG 173.7 53.3 8.7 2.0
DS
DIG 296.0 215.4) 15.6 8.5)
Results NDIG 233.0 96.6 13.1 3.8
CG 215.1 67.8 12.5 2.7
NS
Comparisons to the control group
DIG 233.3 162.7) 12.8 6.5)
NDIG 228.8 98.2 12.7 3.8
The percentage of side-to-side differences for CoP XY CG 247.4 147.5 13.5 5.8
length and CoP velocity were higher in DIG than in CG Side-to-side differences
(P < .01; Table I). There were no other differences between (in%)
DIG or NDIG and CG. DIG 26.7 26.2y 21.3 20.2y
NDIG 2.9 19.2 3.9 13.9
Side-to-side comparisons CG 3.5 24.1y 1.1 18.4y
Unilateral ability index
DIG (DS-EO differences) 104.4 124.7) 6.4 5.0)
There were no side-to-side differences in the control group
DIG (NS-EO differences) 41.7 135.4) 3.6 5.5)
or the NDIG. For DIG, stabilometric values were signifi- NDIG (DS-EO differences 64.0 88.1 4.8 3.6
cantly higher on the dominant pathological shoulder side NDIG (NS-EO differences) 59.8 89.3 4.4 3.5
than on the healthy contralateral nondominant side for CoP CG (DS-EO differences) 49.5 42.0 4.1 1.7
XY length, CoP velocity and unilateral stability index CG (NS-EO differences) 80.3 118.6 5.0 4.7
(P < .01; Table I). EO, eyes open; EC, eyes closed; DS, dominant side; NS, nondominant
side.
Influence of vision The side-to-side differences in percentage was calculated using the
following equation: ([Dom-NonDom]/NonDom*100).
The ability of subjects to maintain their body stable supported on one
There was no influence of vision in the control group. For hand expressed by the difference of the unilateral support value to the
DIG, CoP XY length and CoP velocity values were bilateral support value (‘‘DS - EO differences’’ and ‘‘NS - EO differences’’)
significantly higher for the EC condition than for the EO have been calculated for each variable, and was called ‘‘unilateral
condition (P < .05; Table I). For NDIG, CoP velocity stability index’’.
) Significant side-to-side differences.
values were significantly higher for the EC condition than y
Significant differences compared to the control group.
for the EO condition (P < .05; Table I). z
Significant differences compared to the values in EC conditions.
Discussion recurrent anterior instability shoulder, suggesting a higher
consequence of the sensorimotor deficiency with domi-
The main finding of the present study was that higher sta- nance side differences. However, in the light of these results
bilometric values on the pathological shoulder were found determining whether the weakness is a cause or a conse-
in patients with recurrent anterior instability on the domi- quence of the instability is difficult.
nant shoulder compared with the contralateral shoulder Concerning the method of shoulder sensorimotor control
(considered as healthy) or the control subjects. This assessment using a force platform, no patient experienced
suggests that these patients presented less stability, which pain, anxiety, or discomfort during the assessment, no patient
may come from a sensorimotor control deficiency. No stopped the assessment because of pain, anxiety, or
changes were reported in patients with nondominant discomfort, and no patient reported difficulty in maintaining
Sensorimotor deficiency in shoulder instability 359
the position. This confirms the feasibility of the process in instability of the nondominant shoulder and deficits in
patients with shoulder instability. Moreover, the stabilo- sensorimotor control, if any, were not always reported. We
metric parameter differences in patients with shoulder suggest that the consequences of recurrent anterior insta-
instability show that this assessment method can be relevant bility differ with the dominance of the side involved.
to highlight differences between pathological and healthy Although no side-to-side differences were reported in
subjects; this is the next step for validating this tool and is of control subjects, since the dominant side is used in daily
interest for clinical application. life, a dominant side impairment could have a negative
In control subjects, the results showed no side-to-side effect on the sensorimotor system by detraining. However,
differences on stabilometric parameters. These results are although our results reported that vision did not influence
in agreement with those of previous studies on shoulder the stabilometric parameters in control subjects, there was
proprioception, which reported no differences between the an increase in CoP XY length and/or CoP velocity values in
dominant and the non-dominant sides in healthy (stable) patients with recurrent anterior instability (on the dominant
control subjects.18 These authors suggested that extremity and non-dominant shoulder side). This suggests there are
dominance had no apparent effect on shoulder kines- alterations in the sensorimotor control in patients with
thesia.18 Moreover, proprioceptive values for the contra- recurrent anterior instability, with an increased visual
lateral stable side (considered as healthy) of patients with contribution, both on the dominant and non-dominant
unilateral recurrent anterior instability were similar to those shoulder side.
of control subjects.18 Our results are similar regarding the Some limitations to the method have previously been
stabilometric parameters. Consequently, the contralateral discussed by Edouard et al6 but in this clinical context
stable side (considered as healthy) can be used as a control. further limitations have been found. First, our population
Our results showed that the CoP XY length and CoP could be considered small and secondly, the age distribu-
velocity values increased in patients with recurrent anterior tion of our subjects could be considered as a too wide.
instability on the dominant shoulder side, indicating less However, all the patients involved in this study presented
stability. This lack of stability leads to a need for increased shoulder instability with no other shoulder pathology, and
postural corrections. This could be interpreted as a senso- the controls presented no past or present shoulder
rimotor control deficiency and suggests that this may be pathology. Finally, the reliability of the method has not
associated with recurrent anterior instability. This sensori- been analyzed in a population of patients with concomitant
motor control deficiency could be the consequence of shoulder pathologies.
alterations to any of the components of the sensorimotor
system (proprioception, central integration, neuromuscular
control), as has previously been reported.8,18,25 Smith Conclusion
et al,18 Lephart et al,8 Zuckerman et al,25 and Rokito et al17
reported that shoulder proprioception (joint position sense, From a review of the literature, sensorimotor control
detection of motion, kinesthesia) was significantly affected deficiency is seen to be associated with recurrent ante-
in an unstable shoulder compared to the contralateral stable rior shoulder instability, especially in patients with
shoulder and/or control subjects. Warner et al,23 Tsai a pathological shoulder on their dominant side. Using
et al,21 Rokito et al,17 and Edouard et al4,5 reported a force platform to assess shoulder sensorimotor control
significant isokinetic rotator muscles strength deficits of the is feasible and can allow assessment of the global
shoulder in unstable shoulders compared to contralateral sensorimotor control deficiency present in unstable
stable shoulders and/or control subjects. Our results, which shoulders. In clinical practice, our results confirm that
reported a stabilometric deficit in the unstable shoulder rehabilitation of the sensorimotor control system in-
compared to the contralateral stable shoulder and/or control cluding proprioception and neuromuscular rehabilitation
subjects are coherent with those of these previous exercises should be performed when rehabilitating the
studies,4,5,8,17,18,21,23,25 and suggest there is a sensorimotor shoulder. This can be done efficiently by rehabilitation
deficiency associated with recurrent anterior instability. and/or training including closed kinetic chain and
Our results and the testing process used both contribute plyometric exercises.14,19,24
to our pathophysiological knowledge of these sensorimotor
control deficiencies so often evoked by others and caused
by deficits in joint and muscle receptor input and a related
loss of neuromuscular coordination,25 or due to partial
Disclaimer
differentiation of damaged capsuloligamentous structures,8
None of the authors, their immediate family, nor any
to atrophy caused by disuse, pain, limited shoulder motion,
research foundation with which they are affiliated
apprehension, and/or anxiety,4,5 but most neurophysiolog-
received any financial payments or other benefits from
ical evaluations should also be performed.20
any commercial entity related to the subject of this
However, these results demonstrated no difference in the
article.
stabilometric parameters of patients with recurrent anterior
360 P. Edouard et al.
13. Myers JB, Wassinger CA, Lephart SM. Sensorimotor contribution to
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