The Posterior Shoulder Instability Questionnaire (PSI-Q): Internal consistency, content and criterion validity, responsiveness, and reliability of a new tool for the assessment of posterior shoulder instability.

INTRODUCTION: Posterior shoulder instability (PSI) is an increasingly recognized cause of shoulder dysfunction particularly in young active patients and certain athlete populations. When evaluating the efficacy of treatment for PSI, specific outcome measures for this population are essential. The aim of the current research was to describe the development and evaluation of a patient reported outcome measure (PROM) specific for PSI. METHODS: A retrospective cohort study design of patients with PSI was used to develop and evaluate the "Posterior Shoulder Instability Questionnaire (PSI-Q)". Items for PSI-Q were generated through an expert focus group and existing questionnaires. Preliminary data analysis identified redundancy of items and resulted in the PSI-Q being refined. The final PSI-Q was evaluated on 128 patients with PSI with a structural lesion requiring surgical intervention. Participants were excluded in the absence of a posterior glenohumeral joint lesion. Internal consistency (Cronbach α and corrected item-total correlation), content validity, criterion validity, responsiveness, and test-retest reliability (intraclass correlation coefficient; ICC) were examined. Content validity, criterion validity and responsiveness were compared with the Melbourne Instability Shoulder Score (MISS) and the Western Ontario Shoulder Index (WOSI). The minimum detectable change score (MDC) was calculated. RESULTS: The Cronbach α for the total scale pre and post-intervention was high (α = 0.97). All five domains (Pain, Instability/Weakness/Stiffness, Function, Occupation and Sport, and Quality of Life and Satisfaction) demonstrated acceptable internal consistency for each subsection and the overall score of the scale (α > 0.70). The corrected-item total correlation for each domain were within an acceptable range. The responsiveness of the PSI-Q questionnaire was excellent (effect size, 2.06; standard response mean, 1.34) and was higher than the MISS and WOSI. There were no relevant floor effects and one ceiling effect. Reliability was excellent (ICC (1,1) = 0.93) and the calculated MDC was 10.9 points. DISCUSSION: This study designed and validated a questionnaire specific for measuring symptoms and function in people with structural PSI requiring surgery. The PSI-Q demonstrates good measurement properties and provides an MDC that is useful for researchers and clinicians. In structural PSI, the PSI-Q has a higher responsiveness and more accurately reflects a patient's overall perceived shoulder status compared to current patient reported outcomes for shoulder instability. The psychometric properties of the PSI-Q are still to be determined in a non-surgical population.

Effect of a physiotherapy-directed rehabilitation programme on patients with multidirectional instability of the glenohumeral joint: a multimodal interventional MRI study protocol.

INTRODUCTION: Altered neuromuscular control of the scapula and humeral head is a typical feature of multidirectional instability (MDI) of the glenohumeral joint, suggesting a central component to this condition. A previous randomised controlled trial showed MDI patients participating in the Watson Instability Program 1 (WIP1) had significantly improved clinical outcomes compared with a general shoulder strength programme. The aim of this paper is to outline a multimodal MRI protocol to identify potential ameliorative effects of the WIP1 on the brain. METHODS AND ANALYSIS: Thirty female participants aged 18-35 years with right-sided atraumatic MDI and 30 matched controls will be recruited. MDI patients will participate in 24 weeks of the WIP1, involving prescription and progression of a home exercise programme. Multimodal MRI scans will be collected from both groups at baseline and in MDI patients at follow-up. Potential brain changes (primary outcome 1) in MDI patients will be probed using region-of-interest (ROI) and whole-brain approaches. ROIs will depict areas of functional alteration in MDI patients during executed and imagined shoulder movements (MDI vs controls at baseline), then examining the effects of the 24-week WIP1 intervention (baseline vs follow-up in MDI patients only). Whole-brain analyses will examine baseline versus follow-up voxel-wise measures in MDI patients only. Outcome measures used to assess WIP1 efficacy will include the Western Ontario Shoulder Index and the Melbourne Instability Shoulder Score (primary outcomes 2 and 3). Secondary outcomes will include the Tampa Scale for Kinesiophobia, Short Form Orebro, Global Rating of Change Score, muscle strength, scapular upward rotation, programme compliance and adverse events. DISCUSSION: This trial will establish if the WIP1 is associated with brain changes in MDI. ETHICS AND DISSEMINATION: Participant confidentiality will be maintained with publication of results. Swinburne Human Research Ethics Committee (Ref: 20202806-5692). TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trial Registry (ACTRN12621001207808).

Medium-Term Clinical Outcomes of the Global Icon Stemless Shoulder System: Results of a 2-Year Follow-Up.

The primary aim of this study was to assess the medium-term outcomes of the Global Icon stemless shoulder replacement in patients who have undergone primary total shoulder arthroplasty (TSA) for glenohumeral joint osteoarthritis. A retrospective review of patients who had undergone a TSA using the Global Icon stemless shoulder system was performed. The Western Ontario Osteoarthritis Shoulder (WOOS) Index and Oxford Shoulder Score (OSS) were evaluated pre-operatively and at 12 to 24 months post-operatively. Radiological outcomes, operation time, and post-operative complications were reported. Primary analysis for the WOOS Index and OSS focused on detecting within-group treatment effects at 24 months using a repeated measures ANOVA. Thirty patients were included in the study. Post-surgery, there was a significant improvement at 24 months on the OSS (ES = 0.932, CI: 41.7 to 47.7, p < 0.001) and the WOOS Index (ES = 0.906, CI: 71.9 to 99.8, p < 0.001). Radiographs revealed that no component loosened, migrated, or subsided. The median operative time was 75.5 (IQR: 12.25, range: 18 to 105) min. No implant-related complications were reported. The Global Icon stemless replacements have excellent clinical outcomes in this cohort at 12- and 24-month follow-up with no implant-related complications.

Posterior Shoulder Instability in Tennis Players: Aetiology, Classification, Assessment and Management.

Background: Micro-traumatic posterior shoulder instability (PSI) is an often missed and misdiagnosed pathology presenting in tennis players. The aetiology of micro-traumatic PSI in tennis players is multifactorial, including congenital factors, loss of strength and motor control, and sport-specific repetitive microtrauma. Repetitive forces placed on the dominant shoulder, particularly combinations of flexion, horizontal adduction, and internal rotation contribute to the microtrauma. These positions are characteristic for kick serves, backhand volleys, and the follow-through phase of forehands and serves. The aim of this clinical commentary is to present an overview of the aetiology, classification, clinical presentation, and treatment of micro-traumatic PSI, with a particular focus on tennis players. Level of Evidence: 5.

Video Analysis of Pectoralis Major Injuries in Professional Australian Football Players.

Background: There is little evidence regarding the mechanisms of pectoralis major (PM) injury and player outcomes in Australian Football League (AFL) players. Purposes/Hypothesis: The study aims were to investigate (1) the mechanisms of PM muscle injury in elite AFL players via video analysis and (2) the player profile, method of management, and clinical outcomes of the PM injuries sustained. We hypothesized that the majority of PM tears would occur in outer-range PM positions (hyperextension of the glenohumeral joint). Study Design: Case series; Level of evidence, 4. Methods: We analyzed video of the precipitating event for traumatic PM injuries during AFL competition or training over a 20-year period (2002-2021). The footage was analyzed by 4 experienced assessors, and the following were evaluated: mechanism of injury, injury variables (arm position, initial contact point, visual awareness, and use of taping), player characteristics (age at the time of injury, hand dominance, and history of injury), injury profile (location and size of tear), method of management (operative vs nonoperative), patient outcomes (time to return to full senior training/match play), and complication rates. Results: The mean ± standard deviation age of the players was 26.5 ± 3.1 years (range, 21-32 years). Overall, 22 PM injuries were identified in the AFL injury database for a rate of 1.1 per year; 16 of these injuries had accompanying video footage. We identified 3 mechanisms for PM injury: horizontal hyperextension (62.5%), hyperflexion-abduction (25.0%), and horizontal adduction (sustained tackling; 12.5%). The most common site of the tear was the insertion point of the sternocostal head (91.0%). Twenty players (91.0%) required surgical repair, with 75% undergoing surgery within 1 week (range, 0-26 weeks). The mean return to competition for the surgical repair group was 11.1 weeks (range, 8-15 weeks). The rerupture rate was 5.0% (1 repair; <4 weeks postoperatively in 2004). Conclusion: PM tears in elite male AFL players were due to 1 of 3 distinct mechanisms: horizontal hyperextension, hyperflexion-abduction, and horizontal adduction (sustained tackling). Players returned to play on average 11 weeks after injury. Knowledge regarding mechanisms of injury, player profile, and return-to-sport timelines is important for appropriate medical management and provides potential areas to target for prevention of PM injuries.

Advances in the Non-Operative Management of Multidirectional Instability of the Glenohumeral Joint.

Multidirectional instability (MDI) of the glenohumeral joint refers to symptomatic subluxations or dislocations in more than one direction. The aetiology of MDI is multifactorial, which makes the classification of this condition challenging. A shoulder rehabilitation program is the initial recommended treatment for MDI, however available rehabilitation programs have varying levels of evidence to support their effectiveness. In 2016, we published the details of an evidence-based program for MDI that has been evaluated for efficacy in two single-group studies and a randomised controlled trial. In 2017, we published a clinical commentary on the aetiology, classification, and treatment of this condition. The aim of this paper is to provide an update on the components of these publications with a particular focus on new advances in the non-operative management of this condition.

Unicortical fixation does not compromise bony union in the Latarjet procedure.

Background: Fixation of the coracoid during the Latarjet procedure can be performed with either unicortical or bicortical fixation. There is no clear evidence that the number of cortices fixed affects graft union, but in vitro studies suggest bicortical fixation is desirable. The primary aim of the study was to retrospectively review the coracoid union rates in our Latarjet cohort who have undergone either unicortical or bicortical graft fixation. Methods: A retrospective review of Latarjet patients receiving bicortical or unicortical fixation was performed. The rate of coracoid graft union was assessed via radiographs and computed tomography scans at minimum 8 weeks postoperatively. Primary analysis for graft union was performed with Chi-squared and Fisher's exact tests. Results: A total of 184 patients were enrolled (82 bicortical, 102 unicortical) with 20 patients lost to follow-up. There was no significant difference between union rates of bicortical and unicortical groups (union rate: 94% bicortical, 98% unicortical, P = .25). There were no significant differences in rate of instability recurrence (P = .5) or other postoperative complications (P = .83) between the groups. Discussion: At a minimum follow-up of 8 weeks, bicortical fixation was not shown to have a higher rate of union than unicortical fixation. Performing unicortical fixation is an acceptable practice without compromising bony graft union.

Return to Play After Surgical Treatment of High-Grade Acromioclavicular Joint Injuries in the Australian Football League.

Background: Acromioclavicular joint (ACJ) injuries are the second most common upper limb injuries in the Australian Football League (AFL); however, there is little evidence on the return-to-sport results after surgical stabilization of the ACJ in this sporting population. Purpose: To investigate the return-to-sport time, on-field performance, and patient-reported outcomes in a series of professional AFL players after undergoing ACJ stabilization. Study Design: Case series; Level of evidence, 4. Methods: We conducted a retrospective case series of all AFL players who had undergone open twin-tailed dog-bone ACJ stabilization by a single surgeon between September 2013 and April 2017. Outcome measures included time to return to sport, on-field performance indicators (handballs, tackles, kicks, and AFL Fantasy and Supercoach scores), the Nottingham Clavicle Score, Oxford Shoulder Score, and the Specific Acromioclavicular Score. Patient-reported outcomes were evaluated at a minimum follow-up of 12 months. Results: Of 13 senior listed AFL players who underwent twin-tailed dog-bone surgery, 9 players were included. Mean follow-up was 24.8 months (range, 5-41 months) postoperatively. Mean return-to-sport time was 8.6 weeks for injuries that occurred within the season. The number of kicks, marks, handballs, and tackles as well as AFL Supercoach and Fantasy scores did not significantly change after surgery (P > .05). Outcome measures showed a high level of patient satisfaction after surgery, with a mean Nottingham Clavicle Score of 92.2, Oxford Shoulder Score of 47.7, and the Specific Acromioclavicular Score of 7.5. Conclusion: In a collective of professional AFL players with ACJ injury, our twin-tailed dog-bone technique revealed return to competitive play could be achieved at a mean of 8.6 weeks without compromising on-field performance or patient-reported pain, function, and satisfaction.

Rehabilitation for atraumatic shoulder instability in circus arts performers: delivery via telehealth.

BACKGROUND: The Watson Instability Program (WIP1) is current best evidence for conservative management of atraumatic shoulder instability, but it is unknown if this program can be effectively delivered via tele-consultation. The purpose of this longitudinal pre-post intervention study was to determine the effects of the WIP1 on patient-reported outcome measures, scapular position, shoulder strength, and handstand stability in student circus performers with atraumatic shoulder instability when delivered via tele-consultation. METHODS: Student circus performers aged between 15 and 35 years from the National Institute of Circus Arts were recruited. A 12-week shoulder exercise program was delivered via tele-consultation during the Melbourne, Australia COVID-19 (coronavirus disease 2019) lockdown. The primary outcome measures were the Western Ontario Shoulder Instability Index score and the Melbourne Instability Shoulder Scale score. Secondary outcomes measures included the Orebro Musculoskeletal Pain Questionnaire, the Tampa Scale for Kinesiophobia, and physical assessment measures including strength via handheld dynamometry, scapular position using an inclinometer, and handstand stability via center-of-pressure fluctuation. Patient-reported outcomes were collected at baseline and 6-week, 12-week, 6-month, and 9-month time points, and physical outcomes were measured at baseline and 9-month time points. A repeated-measures mixed model (with effect sizes [ESs] and 95% confidence intervals [CIs]) was used to analyze patient-reported outcomes, handstand data, strength, and scapular measures. Significance was set at P < .05. RESULTS: Twenty-three student circus arts performers completed the study. Significant improvements were found in both Western Ontario Shoulder Instability Index scores (effect size [ES], 0.79 [95% CI, 0.31-1.33] at 6 weeks; ES, 1.08 [95% CI, 0.55-1.6] at 12 weeks; ES, 1.17 [95% CI, 0.62-1.78] at 6 months; and ES, 1.31 [95% CI, 0.74-1.95] at 9 months; P < .001) and Melbourne Instability Shoulder Scale scores (ES, 0.70 [95% CI, 0.22-1.22] at 6 weeks; ES, 0.83 [95% CI, 0.34-1.37] at 3 months; ES, 0.98 [95% CI, 0.46-1.54] at 6 months; and ES, 0.98 [95% CI, 0.43-1.50] at 9 months; P < .001), as well as Orebro Musculoskeletal Pain Questionnaire scores at all follow-up time points. The Tampa Scale for Kinesiophobia scores reached significance at 6 weeks and 12 weeks. Following rehabilitation, we found statistically significant increases in shoulder strength in all positions tested and increased scapular upward rotation measured at end-of-range abduction, as well as during loaded external rotation. The affected arm showed greater instability than the unaffected arm with a significant intervention effect on the affected arm showing a greater consistent anterior-posterior movement pattern. CONCLUSION: In a group of circus performers with atraumatic shoulder instability, treatment with the WIP1 via telehealth resulted in clinically and statistically significant improvements in shoulder symptoms and function.

Return to Professional Australian Rules Football After Surgery for Traumatic Anterior Shoulder Instability.

BACKGROUND: The treatment of traumatic anterior shoulder instability in professional Australian Football League (AFL) players is challenging, with an emphasis on early return to play and avoidance of instability recurrence. PURPOSE: To investigate return-to-sport (RTS) outcomes and complications after 2 different procedures for traumatic anterior shoulder instability in professional AFL players. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We retrospectively reviewed our surgical database for professional AFL players who underwent capsulolabral stabilization or open Latarjet procedure by a single surgeon between 2006 and 2017. Outcomes included RTS, on-field performance, and complications. Between-group analyses for RTS and complications were estimated using Kaplan-Meier survival analyses. Within-group analyses for on-field performance data were performed using paired t tests with significance set at .05. RESULTS: A total of 58 capsulolabral stabilization procedures in 54 players and 32 Latarjet procedures in 29 players were included in the analysis; 93.1% of capsulolabral patients and 96.9% of Latarjet patients returned to professional AFL. The median RTS time was 6.8 months for the capsulolabral group and 7.3 months for the Latarjet group. There was no significant difference in RTS rates between the 2 groups (P = .270). Of those undergoing surgery early in the season, 75% of the capsulolabral and 71% of Latarjet group were able to RTS within the same season, at a mean time of 16.9 weeks and 18.8 weeks, respectively. There was a significant difference in instability recurrence, with 19% for the capsulolabral group and no recurrence in the Latarjet group (P = .017). There was no significant reduction in player on-field performance in either group (P < .05). CONCLUSION: In this study, the median RTS in AFL players was approximately 7 months after capsulolabral and Latarjet surgery with no compromise to on-field performance. Instability-related complications occurred only in the capsulolabral group, and the incidence increased with time.

Intra-Rater and Inter-Rater Reliability of Hand-Held Dynamometry for Shoulder Strength Assessment in Circus Arts Students.

The purpose of this study was to establish the intra-rater and inter-rater reliability of isometric shoulder strength assessment using a hand-held dynamometer (HHD) in functional joint positions in student circus artists with symptomatic atraumatic shoulder instability. METHODS: Over two testing sessions, two experienced physiotherapists assessed the shoulder strength of 24 student circus artists with clinically diagnosed atraumatic shoulder instability. Both the symptomatic and asymptomatic shoulder was assessed using a HHD in 10 functional positions. Intra-class correlation coefficients (ICCs) were calculated to determine the reliability of strength measurements. RESULTS: All examined positions showed moderate-high intra-rater and inter-rater reliability. External rotation at 0° and internal rotation in horizontal flexion at 45° revealed the most reliable results, and the shrug position the least reliable. Inter-rater and intra-rater reliability was high and demonstrated similar results in symptomatic and asymptomatic shoulders by both raters. DISCUSSION: This study demonstrated clinical applicability in reliably measuring functional strength in symptomatic atraumatic instability or asymptomatic shoulders when assessed by experienced therapists using an HHD.

Comparison of 2 Exercise Rehabilitation Programs for Multidirectional Instability of the Glenohumeral Joint: A Randomized Controlled Trial.

BACKGROUND: The recommended initial treatment for multidirectional instability (MDI) of the shoulder is a rehabilitation program, yet there is very low-quality evidence to support this approach. Purpose/Hypothesis: The purpose was to compare the Watson MDI program and Rockwood Instability program among patients with nontraumatic, nonstructural MDI. The hypothesis was that the Watson MDI program would produce clinically and statistically superior outcomes over the Rockwood Instability program. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Forty-one participants with MDI were randomly allocated to the Watson MDI or Rockwood Instability program. Participants attended 12 weekly physiotherapy sessions for exercise prescription. Outcomes were assessed at baseline and 6, 12, and 24 weeks after randomization. Primary outcomes were the Melbourne Instability Shoulder Score (MISS) and the Western Ontario Shoulder Index (WOSI). Secondary outcomes included the Orebro Musculoskeletal Pain Questionnaire, pain, muscle strength, scapular upward rotation, scapular coordinates, global rating of change, satisfaction scales, limiting angle in abduction range, limiting factor in abduction range, and incidence of dislocation. Primary analysis was by intention to treat based on linear mixed models. RESULTS: Between-group differences showed significant effects favoring the Watson program for the WOSI (effect size [ES], 11.1; 95% CI, 1.9-20.2; P = .018) and for the limiting factor in abduction (ES, 0.1; 95% CI, 0.0-1.6; P = .023) at 12 weeks, and for the WOSI (ES, 12.6; 95% CI, 3.4-21.9; P =. 008), MISS (ES, 15.4; 95% CI, 5.9-24.8; P = .002), and pain (ES, -2.0; CI: -2.3 to -0.7, P = .003) at 24 weeks. CONCLUSION: For people with MDI, 12 sessions of the Watson MDI program were more effective than the Rockwood program at 12- and 24-week follow-up. Registration: ACTRN12613001240730 (Australian New Zealand Clinical Trials Registry).

The treatment of multidirectional instability of the shoulder with a rehabilitation programme: Part 2.

BACKGROUND: The most commonly recommended initial treatment for multidirectional instability is a rehabilitation program. Although there is evidence to support the effect of conservative management on this condition, the published literature provides little information on the exercise parameters of such programs. METHODS: This paper is the second part of a two-part series that outlines a six-stage rehabilitation program for multidirectional instability with a focus on scapula control and exercise drills into functional positions. This paper outlines stages 3 to 6 of this rehabilitation program. RESULTS AND CONCLUSIONS: This clinical protocol is currently being tested for efficacy as part of a randomized controlled trial (Australian New Zealand Clinical Trials Registry #ACTRN12613001240730). The information in this paper and additional online supplementary files will provide therapists with adequate detail to replicate the rehabilitation program in the clinical setting.

Multidirectional instability of the glenohumeral joint: Etiology, classification, assessment, and management.

Multidirectional instability of the shoulder is a type of glenohumeral joint shoulder instability. There are discrepancies in the definition and classification of this condition, which can make diagnosis and treatment selection challenging. Knowledge of contributing factors, the typical clinical presentation, and current best evidence for treatment options can assist in the diagnosis and appropriate treatment selection for this pathology. The purpose of this article is to present an overview of the current literature regarding the etiology, classification, assessment, and management of multidirectional instability of the glenohumeral joint.

A comprehensive rehabilitation program for posterior instability of the shoulder.

Posterior shoulder instability is recognised as being less prevalent than anterior instability, however the diagnosis of this pathology is easily overlooked or missed and this may contribute to an underestimation of prevalence. Recently, there has been increasing recognition of this condition and consequently a greater requirement for knowledge of diagnostic procedures and treatment directions. Currently there is limited research into the conservative management of posterior instability, although it is recommended as first-line treatment prior to surgical review, particularly in those with an atraumatic instability mechanism. The aim of this paper is to outline a comprehensive rehabilitation program for the conservative management of posterior instability with a focus on scapular and humeral head control. The information provided includes extensive written information, flowcharts, figures and a table of management parameters that will provide therapists with adequate detail to replicate the program in the clinical setting.

The treatment of multidirectional instability of the shoulder with a rehabilitation program: Part 1.

BACKGROUND: The most commonly recommended initial treatment for multidirectional instability is a rehabilitation program. Although there is evidence to support the effect of conservative management on this condition, the published literature provides little information on the exercise parameters of such programs. In addition, current published rehabilitation programs for multidirectional instability do not focus on scapula stability or exercise drills into functional and sports-specific positions, which are often important aspects to consider in this patient population. METHODS: The aim of this paper (Part 1) is to outline the first two stages of a six-stage rehabilitation program for the conservative management of multidirectional instability with a focus on scapula control and exercise drills into functional positions. RESULTS AND CONCLUSIONS: This clinical protocol is currently being tested for efficacy as part of a randomized controlled trial (Australian New Zealand Clinical Trials Registry #ACTRN12613001240730). The information in this paper and additional online supplementary files will provide therapists with adequate detail to replicate the rehabilitation program in the clinical setting.

Effect of exercise-based management on multidirectional instability of the glenohumeral joint: a pilot randomised controlled trial protocol.

INTRODUCTION: The most commonly recommended treatment for multidirectional instability (MDI) of the shoulder is exercise. Despite this recommendation, there is limited evidence to support the effectiveness of exercise. The aim of this paper is to describe a pilot randomised controlled trial comparing the effectiveness of 2 exercise programmes on outcomes of participants with MDI. METHODS AND ANALYSIS: Consenting participants between 12 and 35 years, with non-traumatic MDI will be randomly allocated to participate in either the Rockwood Instability programme or the Watson MDI programme. Both programmes involve 1 consultation per week for 12 weeks with a physiotherapist to prescribe and progress a home exercise programme. Outcomes will be assessed at baseline, 6, 12, 24 and 52 weeks. Primary outcome measures include the Melbourne Instability Shoulder Score and Western Ontario Shoulder Index. Secondary outcomes include scapular coordinates, scapular upward rotation angles, muscle strength, symptomatic onset, limiting factor and angle of limiting factor in abduction range, incidence of complete glenohumeral joint dislocation, global rating of change, satisfaction scores, the Orebro Musculoskeletal Pain Questionnaire, adverse events and compliance with the home exercise programme. Data will be analysed on intention-to-treat principles and a per protocol basis. DISCUSSION: This trial will evaluate whether there are differences in outcomes between the Rockwood and the Watson MDI programmes for participants with MDI. ETHICS AND DISSEMINATION: Participant confidentiality will be maintained with publication of results. Ethics approval: Faculty of Health Sciences (FHEC12/201). TRIAL REGISTRATION NUMBER: ACTRN12613001240730; Pre-results.

Exercise-based management versus surgery for multidirectional instability of the glenohumeral joint: a systematic review.

BACKGROUND: The most commonly recommended treatment for multidirectional instability (MDI) is exercise-based management, followed by surgery if exercise management fails. We aimed to evaluate the effectiveness of exercise-based management compared with surgery in patients with MDI. Secondary aims were to identify effective protocols and any adverse effects associated with exercise or surgery. METHOD: The Cochrane database of systematic reviews, MEDLINE, EMBASE, CINAHL, PEDro, Current Contents, AMED, AMI, Ausport and Clinical Trials Registers were searched for published and unpublished studies from inception date to August 2014, using the key words multidirectional instability, and glenohumeral and exercise and surgery. Selection criteria included all study designs (except case reports and case series) and participants with MDI where both exercise-based management and surgery were compared in the same study. Inclusion criteria were not limited by outcomes. Risk of bias was assessed using Cochrane criteria. The GRADE approach was used to synthesise the evidence. RESULTS: 4 non-randomised studies met the inclusion criteria. Risk of bias was high in all 4 studies. GRADE assessment revealed very low-quality evidence that surgery was superior to exercise therapy for impairment outcome measures, and exercise was favoured over surgery for patient-reported outcome measures. SUMMARY: The effect of exercise-based management compared with surgery for MDI is difficult to determine due to participant heterogeneity and a high level of bias across included studies.

The effect of exercise-based management for multidirectional instability of the glenohumeral joint: a systematic review.

BACKGROUND: The most commonly recommended treatment for multidirectional instability (MDI) of the glenohumeral joint is exercise-based management. The primary objective of this review was to evaluate the effectiveness of exercise-based management in patients with MDI. The secondary aim was to observe the types of exercise protocols and outcomes used, as well as any adverse results associated with exercise. METHODS: The Cochrane Database of Systematic Reviews, Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PEDro, Current Contents, Allied and Complementary Medicine (AMED), Australasian Medical Index (AMI), Ausport, and Clinical Trials Registers were searched for published and unpublished studies from the inception date to June 2012 using the keywords multidirectional instability, glenohumeral, and exercise. Selection criteria included all study designs (except case reports and case series) and participants with clinically diagnosed MDI using exercise-based management. Inclusion criteria were not limited by outcomes. The authors' own risk-of-bias tool was used for quality assessment of studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to synthesize the evidence. RESULTS: The risk of bias was high in all 7 included studies. For before-and-after comparisons of exercise-based management, GRADE assessment showed very low-quality evidence for improvements in shoulder kinematics, the Rowe score, overall status rating, and peak muscle strength. CONCLUSIONS: The effect of exercise-based management on MDI was variable across the included studies because of study heterogeneity and a high level of bias. There is a need for high-quality intervention studies to be undertaken to validate the effect of exercise for MDI.