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

doi:10.1016/j.jse.2013.08.006

Journal of Shoulder and Elbow Surgery

Volume 23, Issue 1, January 2014, Pages 128-142

https://doi.org/10.1016/j.jse.2013.08.006 Get rights and content

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(AMED), Australasian Medical Index (AMI), Ausport, and Clinical Trials Registers were searched for published and unpublished studies from the inception date to June 2012 using the keywords multidirectional instability, glenohumeral, and exercise.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.

Section snippets

Methods

The authors of this article, before conducting a literature search, developed a review protocol that is summarized herein.

Search results

After omission of duplicate citations, the search yield was 6,619. After omission of citations that were clearly irrelevant, 114 full-text articles were identified for full-text retrieval. Of these, a total of 7 articles met the inclusion criteria for the review. The number of results received at each stage of the review process, along with the number of studies excluded and reasons for exclusion, is outlined in Figure 1.

Characteristics of included studies

Table II displays the characteristics of the included studies. Study

Discussion

For before-and-after comparisons of exercise-based management for MDI, this review showed very low-quality evidence for improvements in shoulder kinematics, The Rowe score, overall status rating, and peak muscle strength. The very low grade of evidence means that any estimate of effect is very uncertain.⁴⁵

For most of the remaining outcomes, lack of data or only post-intervention comparisons with a surgery group meant that the effects of exercise alone over time were almost impossible to

Conclusion

This review showed that there is large heterogeneity among studies of very poor quality for the effects of exercise for MDI. Exercise appears beneficial for patients with nontraumatic MDI; however, its true effects are difficult to evaluate because of literature fraught with high levels of bias. Exercise protocols are poorly defined in the literature, making evaluation of their true effects challenging. There is a fundamental need for high-quality intervention studies to be undertaken to

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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Therapeutic exercise has been considered a useful tool to rehabilitate shoulder pain, namely through its influence on scapular dynamics. Accordingly, the effectiveness of scapular therapeutic exercise needs to be explored. The present study aims to evaluate the effectiveness of scapular therapeutic exercises in shoulder pain and to identify the most effective exercise type (focal or multijoint) and ways of delivering them (as dose and progression).
Search was conducted at EMBASE, Cochrane Library, MEDLINE via PubMed, Web of Science, PEDro (Physiotherapy Evidence Database), and trial registration databases. The meta-analysis considered randomized controlled/crossover trials that compared the effect of scapular exercises against other types of intervention in the shoulder pain, shoulder function, scapular motion, and/or muscular activity. The risk of bias was assessed through the PEDro scale.
From the 8318 records identified, 8 (high to low risk of bias– scoring from 4 to 8 on the PEDro scale) were included. The overall data, before sensitivity analysis, indicated that the scapular therapeutic exercises are: a) more effective than comparators in improving shoulder function (standardized mean difference [SMD] = 0.52 [95% Cl: 0.05, 0.99], P = .03, I² = 76%); and b) as effective as comparators in reducing shoulder pain (SMD = 0.32 [95% Cl: −0.09, 0.73], P = .13, I² = 70%). Subgroup analysis revealed that scapular exercises are more effective in improving shoulder function when the program duration is equal to or higher than 6 weeks (SMD = 0.43 [95% Cl: 0.09, 0.76] P = .01, I² = 21%) and/or when the maximum number of exercise repetitions per session is lower than 30 (SMD = 0.79 [95% Cl: 0.15, 1.42], P = .01, I² = 77%). Only 1 study considered scapular motion as an outcome measure, revealing therapeutic exercise effectiveness to improve scapular range of motion.
Intervention programs involving scapular therapeutic exercises are effective in improving shoulder function, presenting benefits when performed for 6 or more weeks and/or when used up to a maximum of 30 repetitions per exercise, per session.
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Shoulder symptoms are common in patients with hypermobility spectrum disorders (HSD), but few studies focus on identifying factors associated with treatment effects.
To identify baseline and clinical characteristics associated with a better outcome 16 weeks after starting an exercise-based treatment in patients with HSD and shoulder symptoms.
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Self-reported treatment outcome was reported as change between baseline and follow-up after 16 weeks of high-load or low-load shoulder strengthening. Multiple linear and logistic regressions were used to investigate associations of patient expectations of treatment effect, self-efficacy, fear of movement, and symptom duration with change in shoulder function, shoulder pain, quality of life, and patient reported health change. All regression models were performed firstly with adjustments for covariates (age, sex, body mass index, hand dominance, treatment group, and baseline score of the outcome variable) and secondly with additional adjustments for exposure variables.
Expectations of complete recovery were associated with an increased odds of perceiving an important improvement in physical symptoms after a 16-week exercise-based treatment program. Higher self-efficacy at baseline seemed to be associated with improved shoulder function, shoulder pain and quality of life. A higher fear of movement seemed to be associated with increased shoulder pain and decreased quality of life. A longer symptom duration was associated with decreased quality of life.
Expectations of complete recovery, higher self-efficacy, lower fear of movement and shorter symptom duration seem to be important for better treatment outcomes.
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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.
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.
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.
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.
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Citation Excerpt :
In such cases the recommended management is conservative, in the form of physiotherapy rehabilitation, and surgery is regarded as a last resort.3 There is limited evidence to guide physiotherapists regarding the most effective strategies of rehabilitation.4 For this reason the Derby Shoulder Instability Rehabilitation Programme was developed.
There is limited evidence to guide therapists in the management of patients with atraumatic shoulder instability however physiotherapy remains the recommended course of treatment. In this paper we report the updated results of a rehabilitation programme designed for this patient group.
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66 patients were included but 15 were lost to follow-up. Patients attended for a mean of 6.9 sessions over 30 weeks. The mean OISS (n = 51) improved from 38.00 to 21.96 (p < 0.001). Including patients that did not complete follow-up in a sensitivity analysis, the mean OISS (n = 63) improved from 38.41 to 24.46 (p < 0.001). The mean WOSI (n = 51) improved from 45.10% to 85.81% (p < 0.001). In terms of the four WOSI sub-groups: the ‘Physical’ domain improved from mean 47.98%–81.19% (p < 0.001), the ‘Sport & Work’ domain improved from mean 40.17%–82.00% (p < 0.001), the ‘Lifestyle’ domain improved from 50.73% to 83.45% (p < 0.001) and the ‘Emotions’ domain improved from 32.84% to 79.78% (p < 0.001).
For patients with atraumatic shoulder instability the Derby Shoulder Instability Rehabilitation Programme provides significant benefit to patients in terms of pain, stability and function. Further study is required to assess whether such improvements can be sustained in the medium and long terms.
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View all citing articles on Scopus

: No ethics committee approval was required to conduct and produce this systematic review.

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

Background

Methods

Results

Conclusions

Section snippets

Methods

Search results

Characteristics of included studies

Discussion

Conclusion

Disclaimer

Orthop Clin North Am

Clin Sports Med

J Clin Epidemiol

Clin Sports Med

Phys Med Rehabil Clin N Am

J Clin Epidemiol

J Clin Epidemiol

J Clin Epidemiol

J Clin Epidemiol

J Clin Epidemiol

J Clin Epidemiol

J Clin Epidemiol

Aust J Physiother

J Shoulder Elbow Surg

J Electromyogr Kinesiol

J Orthop Sci

J Electromyogr Kinesiol

Curr Orthop

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Arthroscopy

Lancet Infect Dis

J Shoulder Elbow Surg

Clin Sports Med

Arthroscopic treatment of multidirectional shoulder instability in athletes: a retrospective analysis of 2- to 5-year clinical outcomes

Am J Sports Med

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