Neuromuscular exercises for anterior shoulder dislocation
Neuromuscular exercises for anterior shoulder dislocation improve shoulder-related quality of life
Both the groups showed within-group improvements above the MCID
This article gives you 2 options to rehabilitate people after traumatic shoulder dislocation
Introduction
The shoulder girdle is subject to high demands in healthy active individuals. Yet, those who have sustained one or multiple traumatic anterior shoulder dislocation(s) can experience a diminished shoulder-related quality of life. They may be at risk for recurrent shoulder dislocations in the future and treatment to prevent or minimize this risk is advocated. Generally speaking, usually, low load rotator cuff and range of motion exercises are prescribed. However, as the shoulder has to withstand a lot of forces, especially during sporting activities, a more specific rehabilitation is thought to be superior. In this light, targeting the global neuromuscular and proprioceptive systems seems relevant. This superiority trial examined the effects of neuromuscular exercises for anterior shoulder dislocation compared to a standard-of-care home exercise program.
Methods
This RCT was set up to compare a supervised progressive neuromuscular exercise program to a self-managed home exercise program. The neuromuscular exercises for anterior shoulder dislocation were performed in the intervention group as follows.
The neuromuscular exercises for anterior shoulder dislocation included 7 exercises targeting the glenohumeral and scapular muscles. Each exercise had 7 progression levels (basic to elite), with exercises at the basic level performed every day (2×20 repetitions) and exercises at the elite level performed 3 times weekly (2×10 repetitions). The exercises were performed over a period of 12 weeks and each session took about 45 minutes to complete. Next to the supervised sessions also home-exercises were given. Here you find the details of both programs.
The home-based exercise program consisted of 4 exercises with only 2 progression levels. They had only 1 introductory supervised physiotherapy visit and received leaflets and exercise descriptions. Patients had to perform the exercises for 12 weeks, 3 times weekly (2×10 repetitions).
The outcome of interest was the total score of the Western Ontario Shoulder Instability Index (WOSI) at the 12-week follow-up. This scale ranges from 0-2100 where the lower the score, the better. The reported minimal clinically important difference is reported to be 250 points.
Results
Twenty-eight participants were randomly assigned to each group and of these, 27 in the neuromuscular exercise group and 24 in the home-training group were available to analyze at 12 weeks. The included subjects were mostly male (88%) and on average 25.8 years old (+/-5.8y) in the intervention and 26.2 years old in the home-training group (+/-6.4). Most had dislocated their dominant shoulder (89% and 93% in the intervention and home-training group respectively) and this occurred mostly by a fall on the arm (46% and 54%), followed by an accident during athletic activities (32% in both groups; the authors categorized this as “other” and this occurred during soccer, gymnastics, fun wrestling and motocross). In a minority, the dislocation occurred by a pull on the arm (14% and 11%), or by an external force to the shoulder (7% and 4%). In most of the subjects, this was their first anterior dislocation (64 and 67%).
The mean change in the WOSI total score was 655.3 (95% CI, 457.5 to 853.0) in the group performing neuromuscular exercises after shoulder dislocation. In the group performing the home exercises the mean change was 427.2 (95% CI, 245.9 to 608.6). This led to a mean between-group difference of -228,1 points.
Questions and thoughts
The subjects following the neuromuscular training achieved greater improvements in the primary outcome WOSI. The difference between both groups was statistically significant, but the authors state that this difference did not attain the minimal clinically important difference of 250 points. However, the MCID cannot be used to interpret differences between 2 intervention groups as each intervention group difference is a mean value of all subjects in that group. Rather, this MCID should be evaluated within both groups and there, obviously, both groups did attain the MCID.
Looking at these results, it is obvious that the home-based program performed way fewer exercises than the intervention group receiving neuromuscular exercises for anterior shoulder dislocation. The fact that more training is performed in the intervention group may likely have a beneficial effect on the primary outcome. Not only performing more exercises but also progressing those exercises through 7 levels will likely have a greater effect than performing 4 basic exercises with only 2 levels. A more logical comparator would have been an equally-dosed, but less specific exercise program in my opinion. It would have been interesting to see how the control group would have performed by doing the same but only the basic-level exercises (without progression towards the elite level like in the intervention group). Can you expect the same benefits from a rehabilitation program that is less intensive than a more frequently performed program that is way more progressive and intense? Therefore, I’m not sure if this may be an equal comparator. Stunning to me is the fact that the intervention group did not outperform the control group as you look at the exercises in detail performed by both groups. Possibly, the 12-week period was short to induce more improvement, or not all participants from the intervention group achieved the elite progression levels? However, participants from both groups indicated that they were satisfied with both programs and no serious adverse events occurred.
Talk nerdy to me
The protocol required participants to have at least 2 positive tests on the apprehension, relocation, surprise tests to be eligible candidates. However, the trial deviated from the protocol as many of these patients did not have clinical signs of anterior shoulder instability. This seems a bit weird but again reflects the fact that a clinical test does not always reflect an individual’s complaint. The participants included had to experience unidirectional anterior shoulder instability, and it was radiologically verified that at least a primary or recurrent anterior dislocation had taken place. On top of that, patients had to report difficulties in activities of daily living in the previous week. I find it a bit odd that the authors include participants with a first-time shoulder dislocation and label them as having unidirectional anterior shoulder instability. Adding on to that, in nearly two-thirds of included participants this anterior dislocation was only their first shoulder dislocation. Rather, these participants had a traumatic shoulder dislocation, but it doesn’t mean that all of these individuals had shoulder instability.
A minimum of 36 participants per group were required according to the sample size calculation. Yet, only 28 subjects were randomized in each group. So this is an important limitation to keep in mind. Another important limitation of this study lies in the fact that we cannot say what exactly caused the treatment effect. It can be the different exercises, the supervision and guidance, the neuromuscular aspect, or a combination. Even a placebo may have had a spell on the results, as the participants performing neuromuscular exercises for anterior shoulder dislocation were supervised and may have had a better expectations therefore.
Take home messages
Neuromuscular exercises for anterior shoulder dislocation are safe and effective in improving shoulder-related quality of life. Both the groups performing neuromuscular and home exercises showed within-group improvements above the MCID, the latter less. This study gives you 2 exercise programs that you can use: the more frequent and intense program can be given to highly motivated patients or patients who want in-person rehab supervision. The home program can be given to those in lack of time or less-motivated people.
Reference
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