Elsevier

Journal of Hand Therapy

Volume 17, Issue 2, April–June 2004, Pages 229-242
Journal of Hand Therapy

Scientific/Clinical Articles
The effectiveness of rehabilitation for nonoperative management of shoulder instability: a systematic review

https://doi.org/10.1197/j.jht.2004.02.010Get rights and content

Abstract

A systematic review of published evidence on conservative management was conducted in Medline, Cumulative Index to Nursing & Allied Health Literature (CINAHL), Database of Abstracts of Reviews of Effects (DARE), Allied & Alternative Medicine (AMED), PubMed, and Cochrane. For each article, two of the four reviewers conducted abstract selection and critical appraisal. Disagreements were resolved through consensus and third review, if required. Level of evidence and quality on a 24-item quantitative critical appraisal form were determined for all articles meeting selection criteria. Outcomes considered included recurrence of instability and return to premorbid function. Overall, the quantity and quality of evidence were low. Immobilization for three to four weeks followed by a structured 12-week rehabilitation program of range of motion and glenohumeral and scapular stability exercises for patients with primary dislocations to maximize return to premorbid activity level is supported by weak evidence. Level II evidence suggests that recurrence is lower in patients managed with surgical as compared with conservative management. Further research is required to delineate the optimal approach to rehabilitation and its role in secondary prevention.

Section snippets

Methods

A primary literature search of computerized bibliographic databases was conducted with an English-only language restriction and a date restriction of articles published January 1980 up to and including April 2003. The databases chosen were Medline, the Cumulative Index to Nursing & Allied Health (CINAHL), DARE, AMED, PubMed, and Cochrane. Search terms used included shoulder, shoulder joint, instability, dislocation, subluxation, treatment, rehabilitation, exercise therapy, physiotherapy,

Results

Table 1 lists the consensus scores of methodological quality for each of the 19 articles meeting the inclusion criteria. Table 1 describes 24 specific research design elements of the studies appraised whereby a score of 2 represents the best score and indicates a high-quality approach to this element of research design. A score of 1, in turn, represents fair quality or that the methodological criteria were only partially met, whereas a score of 0 represents low-quality research design or unmet

Disease-specific quality of life

One high-quality RCT included the validated Western Ontario Shoulder Instability Index (WOSI) as an outcome measure to assess disease-specific quality of life in 40 skeletally mature patients under the age of 30 years who had previously sustained a first traumatic anterior shoulder dislocation.24 The results showed that three weeks' immobilization followed by a rehabilitation protocol is less effective than arthroscopic surgery followed by the same protocol for improving quality of life.24

Patient satisfaction

One

Reviewers' conclusions and recommendations

Although there are numerous protocols for the conservative management of traumatic or atraumatic shoulder instability published in scientific journals, the majority are based only on physiological rationale and biological evidence rather than on specific clinical trials. This reflects the paucity of such evidence, with the few primary research articles published since 1980 consisting of generally low methodological quality. A conservative inclusion criteria threshold score of 18 on the standard

Limitations of the review

The current review is limited by a paucity of primary evidence in the literature pertaining to conservative management strategies for shoulder instability. Generally, the methodological quality of these studies is quite low, and many fail to provide sufficient descriptions of conservative treatment protocols. This weakness limits both the strength and clarity of our conclusions. However, it should be noted that the quality of some studies may have been underestimated by the critical appraisal

Clinical practice recommendations

The results of this review are summarized to assist practitioners and therapists in clinical decision making when treating patients with shoulder instability. Although the present evidence is weak, the current best evidence suggests that: (1) Immobilization for three to four weeks followed by a structured 12-week rehabilitation program of range-of-motion and glenohumeral and scapular stability exercises is recommended for patients with primary dislocations to maximize return to premorbid

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