Introduction

Acute traumatic shoulder dislocations are common. The NICE guidelines indicate that both younger and older people are affected. In younger individuals, it occurs mostly in men aged 16-20 years and is attributed to sporting injuries. In the older population, women are more affected in their sixties and seventies, and here the occurrence is more related to falls. The rehabilitation for anterior shoulder dislocation is most often non-operative. It includes supporting the arm in a sling for up to two weeks and an intensive rehabilitation period of up to six months may be necessary afterwards. The authors indicate that this trial was necessary as there are not many studies making the comparison of rehabilitation pathways after the wear of the sling. To determine the effectiveness of physiotherapy rehabilitation for an acute traumatic anterior shoulder dislocation after the use of a sling, it was compared against a session of advice.

Methods

This study was conducted in the ARTISAN trial, across 41 NHS institutions in the United Kingdom. Participants in the trial were eligible when they had a first-time acute traumatic anterior shoulder dislocation, which was confirmed on RX. They were eligible in the absence of neurovascular complications or bilateral dislocations.

All participants were given a sling and received an appointment for an advice session within 6 weeks of their shoulder dislocation. Here, their shoulder was examined and they received a 1-hour session of advice to help them self-manage the condition. The advice session consisted of core components on education, progressive exercises, and exercise planning to enhance self-management behaviors.

Following this initial advice session, the participants were randomized to receive either only this advice session or to receive additional physiotherapy sessions on top of the advice session.

Those randomized to receive advice only had the option to contact the investigators to self-refer to physiotherapy when they experienced no recovery. In this group, the physiotherapy sessions were thus optional.

The participants that were randomly assigned to advice and physiotherapy could enter rehabilitation sessions of 30 minutes duration for up to 4 months. No minimum or maximum number of sessions was specified, but the trial protocol indicated that the number and frequency of any additional sessions were jointly agreed between the clinician and participant, in keeping with standard practice.

The Oxford Shoulder Instability Score was the primary outcome measure. This questionnaire is a patient-reported outcome measure that has 12 questions. The minimum score is 0 which means worst function and the maximum score is 48, representing best function. The questions relate to daily activities that are relevant in people with shoulder instability and were designed to assess the outcome of treatment. This outcome was measured at 6 months following the dislocation.

A worthwhile between-group difference for the Oxford Shoulder Instability Score was set at 4 points.

Results

Four hundred and eighty-two people were randomly assigned to receive advice and physiotherapy rehabilitation for anterior shoulder dislocation or advice only. Most of the participants were male (66%) and they had a mean age of 45 years. The baseline characteristics revealed that the groups were equal at baseline.

The primary intention-to-treat analysis revealed there was no significant difference in the Oxford shoulder instability score between the two groups at the six-month outcome. The mean difference favored physiotherapy with 1.5 but the 95% confidence interval revealed that it was not significant, nor did it attain the prespecified threshold of minimum worthwhile mean difference as it ranged from −0.3 to 3.5.

The rate of complications and the nature of the complications were similar across groups. The complication that arose most commonly was a tear of the rotator cuff.

Questions and thoughts

Eighteen percent of participants self-referred to receive physiotherapy rehabilitation for anterior shoulder dislocation. What were their characteristics: who may need physiotherapy right away? Their characteristics were not mentioned, unfortunately.

Rotator cuff tears were the most common complication reported in this study, occurring in about 10%. Shoulder re-dislocations were relatively uncommon and occurred in 1-3%. This is quite low, and this low number may be attributed to the relatively short duration of follow-up: 6 months.

According to the protocol, these complications would be defined into three categories:

1. Predefined complications directly related to the interventions.
2. Predefined complications directly caused by the primary dislocation event not identified by the initial assessing clinician, but were subsequently identified.
3. Complications not related to the intervention or dislocation event and will subsequently not be formally analyzed or reported.

Unfortunately, the categories of the complications were not mentioned in the study, nor the supplementary data. Here we cannot make assumptions about whether one group had for example more complications directly related to the intervention, whereas others may have had complications that were caused by the initial dislocation.

The table hereunder shows the components of the physiotherapy program. I remark that many of the exercises were mobilization exercises and assisted movements.

• Could the intervention have led to better results when more strengthening exercises and proprioception had been given?
• Furthermore, there were no details given about when progressions are made: when certain strength was achieved or more based on the clinician’s experience and opinion.

These observations prompt me to remain cautious about the outcomes. A robust RCT normally clearly defines progression and regression criteria and to determine this, would sample strength outcomes/limb symmetry indices (using a dynamometer) or use field testing. I understand that this was a pragmatic trial but this would nonetheless have had at least some progression criteria and strength measurements in my opinion. This way we can “rate” the quality of the physiotherapy received. It is possible that the physiotherapy administered in this trial did not push the patient’s limits and as such possibly led to the lack of a difference between physiotherapy and one advice session.

Talk nerdy to me

The main analysis was supported by the secondary outcome measures, again here no difference between the groups was revealed. The per-protocol analysis which analyzed the participants who crossed over to receive the optional physiotherapy program, found no differences between the groups. The sensitivity analysis for missingness did not reveal a significant difference. When a subgroup analysis based on age or arm dominance was undertaken, the differences in the outcomes were only little influenced. It thus seems that the findings are robust and as such we can assume that a session of advice merits the improvements seen.

Loss to follow-up was relatively high, with 27% not filling in the Oxford score at 6 months.

Adherence was reported to be high.

• In the advice-only group, adherence was 98% with 81% of 240 participants receiving advice only and 18% (n=42) of participants self-referring to receive physiotherapy. Only 1% of participants in the advice-only group crossed over to receive physiotherapy due to the clinician’s recommendation.
• In the group randomized to advice and further physiotherapy, adherence was 100%, with all participants offered physiotherapy. Within this group, 69% of 242 participants had a complete program of physiotherapy, defined as completing all sessions scheduled over the four months, 10% of participants did not attend any additional appointments, and 12% of participants did not attend after one appointment. After the four-month treatment period, 7% of participants were receiving ongoing management.

It is not exactly clear to me how the adherence can be 100% when only 69% completed the sessions. I assumed that 100% of participants filled out the Oxford score at 6 months and were therefore categorized as “adherent”, despite they did not adhere to the physiotherapy program. However, this is not possible since 73% percent of participants completed the Oxford score at 6 months. Here I keep guessing what gave this 100% adherence score.

Take home messages

Empowering people to make their own treatment decisions gave people recuperating from a first-time shoulder dislocation more freedom in deciding whether or not they needed additional supervised treatment. It seems that a good session of advice (1 hour) where self-management options are discussed is sufficient in the rehabilitation of anterior shoulder dislocation. Yet, as the trial didn’t elaborate on the physiotherapy program progressions, we assume that the effectiveness can be further improved.

Reference

Kearney RS, Ellard DR, Parsons H, Haque A, Mason J, Nwankwo H, Bradley H, Drew S, Modi C, Bush H, Torgerson D, Underwood M; The ARTISAN collaborators; ARTISAN collaborators. Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomised controlled trial. BMJ. 2024 Jan 17;384:e076925. doi: 10.1136/bmj-2023-076925. PMID: 38233068; PMCID: PMC10792684.

Additional reference

Kearney RS, Dhanjal G, Parsons N, Ellard D, Parsons H, Haque A, Karasouli E, Mason J, Nwankwo H, Brown J, Liew Z, Drew S, Modi C, Bush H, Torgerson D, Underwood M. Acute Rehabilitation following Traumatic anterior shoulder dISlocAtioN (ARTISAN): protocol for a multicentre randomised controlled trial. BMJ Open. 2020 Nov 19;10(11):e040623. doi: 10.1136/bmjopen-2020-040623. PMID: 33444204; PMCID: PMC7678365.