The role of exercise in the conservative treatment of the anterior shoulder dislocation

Effectiveness of combined surgical and exercise-based interventions following primary traumatic anterior shoulder dislocation: a systematic review and meta-analysis

OBJECTIVE

To investigate the effectiveness, risk of recurrence and return to activity (RTA) of surgery combined with exercise-based interventions (EBI) versus EBI alone after traumatic anterior shoulder dislocation (ASD).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Systematic literature search (MEDLINE, Web of Science, Scopus, Google Scholar).

ELIGIBILITY

Studies focused on EBI or EBI as a part of postoperative care for adults with an ASD, written in English, and published after 1990. We excluded diagnostic, assessment-based studies on individuals experiencing recurrent shoulder dislocations, concomitant shoulder injury, animal or cadaveric studies. Primary outcomes were dislocation RTA. Secondary outcomes were self-reported outcome measures, strength and range of motion. Random-effects meta-analysis was used to estimate the effect of EBI (SMD; Hedges' g, RR). The Grading of Recommendations Assessment, Development and Evaluation approach was used to assess the certainty of evidence.

RESULTS

Sixty studies were included (n=3598); seven were meta-analysed (n=345). The mean age of participants in the included studies was 26.71±9.19 and 56% of those included were male. Of the 60 studies included in the systematic review, 29 were fair quality (48.3%), 15 studies were good quality (25%) and 16 studies were poor quality (26.7%), (k=0.66). Individuals who underwent EBI alone were 2.03 times more likely to experience recurrent instability than individuals who underwent EBI in conjunction with surgery (RR 2.03, 95% CI 1.03 to 3.97). Individuals who underwent EBI with surgery appeared 1.81 times more likely to RTA than those who underwent EBI alone, although results were not statistically significant (RR 1.81, 95% CI 0.96 to 3.43).

CONCLUSIONS

Surgery combined with EBI is more effective in reducing the risk of recurrence and possibly increasing RTA than EBI alone after traumatic ASD.

Bodyblade™ Training in Athletes with Traumatic Anterior Shoulder Instability

Background

The Bodyblade™ has the potential of enhancing conservative management of Traumatic Anterior Shoulder Instability (TASI).

Purpose

The purpose of this study was to compare three different protocols: Traditional, Bodyblade™, and Mixed (Traditional & Bodyblade™) for shoulder rehabilitation on athletes with TASI.

Study Design

Randomized-controlled longitudinal training study.

Methods

Thirty-seven athletes (age = 19.9±2.0 years) were allocated into Traditional, Bodyblade™, and Mixed (Traditional/Bodyblade™) training groups (3×week for 8-weeks). The traditional group used resistance bands (10-15 repetitions). The Bodyblade™ group transitioned from classic to the pro model (30-60-s repetitions). The mixed group converted from the traditional (weeks 1-4) to the Bodyblade™ (weeks 5-8) protocol. Western Ontario Shoulder Index (WOSI) and the UQYBT were evaluated at baseline, mid-test, post-test, and at a three-month follow-up. A repeated-measures ANOVA design evaluated within and between-group differences.

Results

All three groups significantly (p=0.001, eta2: 0.496) exceeded WOSI baseline scores (at all timepoints) with training (Traditional: 45.6%, 59.4%, and 59.7%, Bodyblade™: 26.6%, 56.5%, and 58.4%, Mixed: 35.9%, 43.3% and 50.4% respectively). Additionally, there was a significant (p=0.001, eta2: 0.607) effect for time with mid-test, post-test and follow-up exceeding baseline scores by 35.2%, 53.2% and 43.7%, respectively. The Traditional and Bodyblade™ groups (p=0.049, eta2: 0.130) exceeded the Mixed group UQYBT at post-test (8.4%) and at three-month follow-up (19.6%). A main effect (p=0.03, eta2: 0.241) for time indicated that WOSI mid-test, post-test and follow-up exceeded the baseline scores by 4.3%, 6.3% and 5.3%.

Conclusions

All three training groups improved their scores on the WOSI. The Traditional and Bodyblade™ groups demonstrated significant improvements in UQYBT inferolateral reach scores at post-test and three-month follow-up compared to the Mixed group. These findings could lend further credibility to the role of the Bodyblade as an early to intermediate rehabilitation tool.

LEVEL OF EVIDENCE

3.

Conservative management following closed reduction of traumatic anterior dislocation of the shoulder

BACKGROUND

Acute anterior shoulder dislocation, which is the most common type of dislocation, usually results from an injury. Subsequently, the shoulder is less stable and is more susceptible to re-dislocation or recurrent instability (e.g. subluxation), especially in active young adults. After closed reduction, most of these injuries are treated with immobilisation of the injured arm in a sling or brace for a few weeks, followed by exercises. This is an update of a Cochrane Review first published in 2006 and last updated in 2014.

OBJECTIVES

To assess the effects (benefits and harms) of conservative interventions after closed reduction of traumatic anterior dislocation of the shoulder. These might include immobilisation, rehabilitative interventions or both.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, PEDro and trial registries. We also searched conference proceedings and reference lists of included studies. Date of last search: May 2018.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials comparing conservative interventions with no treatment, a different intervention or a variant of the intervention (e.g. a different duration) for treating people after closed reduction of a primary traumatic anterior shoulder dislocation. Inclusion was regardless of age, sex or mechanism of injury. Primary outcomes were re-dislocation, patient-reported shoulder instability measures and return to pre-injury activities. Secondary outcomes included participant satisfaction, health-related quality of life, any instability and adverse events.

DATA COLLECTION AND ANALYSIS

Both review authors independently selected studies, assessed risk of bias and extracted data. We contacted study authors for additional information. We pooled results of comparable groups of studies. We assessed risk of bias with the Cochrane 'Risk of bias' tool and the quality of the evidence with the GRADE approach.

MAIN RESULTS

We included seven trials (six randomised controlled trials and one quasi-randomised controlled trial) with 704 participants; three of these trials (234 participants) are new to this update. The mean age across the trials was 29 years (range 12 to 90 years), and 82% of the participants were male. All trials compared immobilisation in external rotation (with or without an additional abduction component) versus internal rotation (the traditional method) following closed reduction. No trial evaluated any other interventions or comparisons, such as rehabilitation. All trials provided data for a follow-up of one year or longer; the commonest length was two years or longer.All trials were at some risk of bias, commonly performance and detection biases given the lack of blinding. Two trials were at high risk of selection bias and some trials were affected by attrition bias for some outcomes. We rated the certainty of the evidence as very low for all outcomes.We are uncertain whether immobilisation in external rotation makes a difference to the risk of re-dislocation after 12 months' or longer follow-up compared with immobilisation in internal rotation (55/245 versus 73/243; risk ratio (RR) 0.67, 95% confidence interval (CI) 0.38 to 1.19; 488 participants; 6 studies; I² = 61%; very low certainty evidence). In a moderate-risk population with an illustrative risk of 312 per 1000 people experiencing a dislocation in the internal rotation group, this equates to 103 fewer (95% CI 194 fewer to 60 more) re-dislocations after immobilisation in external rotation. Thus this result covers the possibility of a benefit for each intervention.Individually, the four studies (380 participants) reporting on validated patient-reported outcome measures for shoulder instability at a minimum of 12 months' follow-up found no evidence of a clinically important difference between the two interventions.We are uncertain of the relative effects of the two methods of immobilisation on resumption of pre-injury activities or sports. One study (169 participants) found no evidence of a difference between interventions in the return to pre-injury activity of the affected arm. Two studies (135 participants) found greater return to sports in the external rotation group in a subgroup of participants who had sustained their injury during sports activities.None of the trials reported on participant satisfaction or health-related quality of life.We are uncertain whether there is a difference between the two interventions in the number of participants experiencing instability, defined as either re-dislocation or subluxation (RR 0.84, 95% CI 0.62 to 1.14; 395 participants, 3 studies; very low certainty evidence).Data on adverse events were collected only in an ad hoc way in the seven studies. Reported "transient and resolved adverse events" were nine cases of shoulder stiffness or rigidity in the external rotation group and two cases of axillary rash in the internal rotation group. There were three "important" adverse events: hyperaesthesia and moderate hand pain; eighth cervical dermatome paraesthesia; and major movement restriction between 6 and 12 months. It was unclear to what extent these three events could be attributed to the treatment.

AUTHORS' CONCLUSIONS

The available evidence from randomised trials is limited to that comparing immobilisation in external versus internal rotation. Overall, the evidence is insufficient to draw firm conclusions about whether immobilisation in external rotation confers any benefit over immobilisation in internal rotation.Considering that there are several unpublished and ongoing trials evaluating immobilisation in external versus internal rotation, the main priority for research on this question consists of the publication of completed trials and the completion and publication of ongoing trials. Meanwhile, evaluation of other interventions, including rehabilitation, is warranted. There is a need for sufficiently large, good-quality, well-reported randomised controlled trials with long-term follow-up. Future research should aim to determine the optimal immobilisation duration, precise indications for immobilisation, optimal rehabilitation interventions, and the acceptability of these different interventions.

Hand dominance in traumatic shoulder dislocations

Background

Shoulder dislocations are common injuries among athletes. Patients with instability after their injury often require stabilization procedures for treatment. The primary outcome measure was to see whether there was any correlation between the side of traumatic shoulder dislocation and dominance of hand. Secondary outcomes were to look at subgroups of age and sporting discipline.

Materials and methods

This study recruited all patients with a frank dislocation that required arthroscopic surgical stabilization who attended the same private orthopedic surgeon. Exclusion criteria included injury without frank dislocation, nonsport-related injuries, and ambidexterity. Data were collected for 325 of 365 patients (89.0% response rate)

Results

There were 278 right hand-dominant patients (85.5%), with 136 (48.9%) requiring arthroscopic stabilization of their dominant side for dislocation. Of the remaining 47 left hand-dominant patients, 17 (36.2%) required operations on their dominant arm. In total, 153 patients (47.1%) dislocated their dominant shoulder and 172 (52.9%) dislocated their nondominant shoulder, with an odds ratio of 1.692 (95% confidence interval, 0.893-3.205).

Conclusions

This study suggests that there is no statistical significance between the side of shoulder dislocation and hand dominance of patients with shoulder dislocation. Future research could investigate further the causal relationship between hand dominance and mechanisms of injury.

Conservative management following closed reduction of traumatic anterior dislocation of the shoulder

BACKGROUND

Acute anterior dislocation, which is the most common type of shoulder dislocation, usually results from an injury. Subsequently, the shoulder is less stable and is more susceptible to re-dislocation, especially in active young adults. This is an update of a Cochrane review first published in 2006.

OBJECTIVES

To assess the effects (benefits and harms) of conservative interventions after closed reduction of traumatic anterior dislocation of the shoulder. These might include immobilisation, rehabilitative interventions or both.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 8), MEDLINE (1946 to September 2013), EMBASE (1980 to Week 38, 2013), CINAHL (1982 to September 2013), PEDro (1929 to November 2012), OTseeker (inception to November 2012) and trial registries. We also searched conference proceedings and reference lists of included studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing various conservative interventions versus control (no or sham treatment) or other conservative interventions applied after closed reduction of traumatic anterior dislocation of the shoulder.

DATA COLLECTION AND ANALYSIS

All review authors independently selected trials, assessed risk of bias and extracted data. Study authors were contacted for additional information. Results of comparable groups of trials were pooled.

MAIN RESULTS

We included three randomised trials and one quasi-randomised trial, which involved 470 participants (371 male) with primary traumatic anterior dislocation of the shoulder reduced by various closed methods. Three studies evaluated mixed populations; in the fourth study, all participants were male and 80% were soldiers. All trials were at some risk of bias but to a differing extent. One was at high risk in all domains of the risk of bias tool, and one was at unclear or high risk in all domains; the other two trials were deemed to have predominantly low risk across all domains. Overall, reflecting both the risk of bias and the imprecision of findings, we judged the quality of evidence to be "very low" for all outcomes, meaning that we are very uncertain about the estimates of effect.The four trials evaluated the same comparison - immobilisation in external rotation versus internal rotation - and each of our three primary outcomes (re-dislocation, patient-reported outcome measures (PROMs) for shoulder instability and resumption of activities) was reported by one or more of the trials, with two-year or longer follow-up. Pooling was possible for "re-dislocation" (three trials) and for aspects of "resumption of sport/activities at pre-injury level" (two trials).There was no evidence to show a difference between the two groups in re-dislocation at two-year or longer follow-up (risk ratio (RR) 1.06 favouring internal rotation, 95% confidence interval (CI) 0.73 to 1.54; P value 0.77; 252 participants; three trials). In a low-risk population, with an illustrative baseline risk of 247 re-dislocations per 1000, these data equate to 15 more (95% CI 67 fewer to 133 more) re-dislocations per 1000 after immobilisation in external rotation. In a medium-risk population, with an illustrative baseline risk of 436 re-dislocations per 1000, the data equate to 26 more (95% CI 118 fewer to 235 more) re-dislocations after immobilisation in external rotation.Nor was evidence found to show a difference between the two groups in return to pre-injury levels of activity at two-year or longer follow-up (RR 1.25 favouring external rotation, 95% CI 0.71 to 2.2; P value 0.43; 278 participants; two trials). In a low-risk population, with an illustrative baseline risk of 204 participants per 1000 returning to pre-injury levels of activity, this equates to 41 more (95% CI 59 fewer to 245 more) participants per 1000 resuming activity after immobilisation in external rotation. In a high-risk population, with an illustrative baseline risk of 605 participants per 1000 returning to pre-injury levels of activity, this equates to 161 more (95% CI 76 fewer to 395 more) participants per 1000 resuming activity after immobilisation in external rotation.One trial reported that the difference between the two groups in Western Ontario Shoulder Instability Index scores, analysed using non-parametric statistics, was "not significant (P = 0.32)". Of our secondary outcomes, pooling was possible for "any instability" (two trials) and for important adverse events (three events, two trials). However, adverse event data were collected only in an ad hoc way, and it is unclear whether identification and reporting of such events was comprehensive. No report addressed participant satisfaction or health-related quality of life outcome measures.There was no evidence confirming a difference between the two positions of immobilisation in any of the primary or secondary outcomes; for each outcome, the confidence intervals were wide, covering the possibility of substantial benefit for each intervention.

AUTHORS' CONCLUSIONS

Numerous conservative strategies may be adopted after closed reduction of a traumatic anterior dislocation of the shoulder, and many warrant investigation. However, our review reveals that evidence from randomised controlled trials is only available for a single approach: immobilisation in external rotation versus immobilisation in the traditional position of internal rotation. Moreover, this evidence is insufficient to demonstrate whether immobilisation in external rotation confers any benefit over immobilisation in internal rotation.We identified six unpublished trials and two ongoing trials that compare immobilisation in external versus internal rotation. Given this, the main priority for research on this question consists of the publication of completed trials, and the completion and publication of ongoing trials. Meanwhile, increased attention to other interventions is required. Sufficiently powered, good quality, well reported randomised controlled trials with long-term surveillance should be conducted to examine the optimum duration of immobilisation, whether immobilisation is necessary at all (in older age groups particularly), which rehabilitative interventions work best and the acceptability to participants of different care strategies.