BESS/BOA patient care pathways: Atraumatic shoulder instability

Noorani, Ali; Goldring, Michael; Jaggi, Anju; Gibson, Jo; Rees, Jonathan; Bateman, Marcus; Falworth, Mark; Brownson, Peter

doi:10.1177/1758573218815002

Cited by 16 publications

(28 citation statements)

References 46 publications

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“…Frozen shoulder is a common complaint in people with diabetes, with an incidence ranging between 10% and 36%. 117 Our interview findings indicate that the presence or absence of diabetes did not influence trial participants' experiences of the trial interventions. These support the main trial findings, which indicate no significant between-group differences in the mean OSS between diabetic and non-diabetic participants across the treatment arms.…”

Section: Frozen Shoulder and Diabetesmentioning

confidence: 70%

“…Finally, 30% of trial participants had diabetes, a common complaint in people with frozen shoulder, ranging between 10% and 36%. 117 Participants with diabetes tended to have poorer outcomes at all time points, which is why we stratified for this at randomisation. 62 The subgroup analyses, however, showed that whether or not participants were diabetic did not have a statistically significant effect on treatment comparisons.…”

Section: Characteristics Of the Trial Populationmentioning

confidence: 99%

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Surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder: the UK FROST three-arm RCT

Brealey

Northgraves

Kottam

et al. 2020

Health Technol Assess

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Background Frozen shoulder causes pain and stiffness. It affects around 10% of people in their fifties and is slightly more common in women. Costly and invasive surgical interventions are used, without high-quality evidence that these are effective. Objectives To compare the clinical effectiveness and cost-effectiveness of three treatments in secondary care for adults with frozen shoulder; to qualitatively explore the acceptability of these treatments to patients and health-care professionals; and to update a systematic review to explore the trial findings in the context of existing evidence for the three treatments. Design This was a pragmatic, parallel-group, multicentre, open-label, three-arm, randomised superiority trial with unequal allocation (2 : 2 : 1). An economic evaluation and a nested qualitative study were also carried out. Setting The orthopaedic departments of 35 hospitals across the UK were recruited from April 2015, with final follow-up in December 2018. Participants Participants were adults (aged ≥ 18 years) with unilateral frozen shoulder, characterised by restriction of passive external rotation in the affected shoulder to < 50% of the opposite shoulder, and with plain radiographs excluding other pathology. Interventions The inventions were early structured physiotherapy with a steroid injection, manipulation under anaesthesia with a steroid injection and arthroscopic capsular release followed by manipulation. Both of the surgical interventions were followed with post-procedural physiotherapy. Main outcome measures The primary outcome and end point was the Oxford Shoulder Score at 12 months post randomisation. A difference of 5 points between early structured physiotherapy and manipulation under anaesthesia or arthroscopic capsular release or of 4 points between manipulation under anaesthesia and arthroscopic capsular release was judged clinically important. Results The mean age of the 503 participants was 54 years; 319 were female (63%) and 150 had diabetes (30%). The primary analyses comprised 473 participants (94%). At the primary end point of 12 months, participants randomised to arthroscopic capsular release had, on average, a statistically significantly higher (better) Oxford Shoulder Score than those randomised to manipulation under anaesthesia (2.01 points, 95% confidence interval 0.10 to 3.91 points; p = 0.04) or early structured physiotherapy (3.06 points, 95% confidence interval 0.71 to 5.41 points; p = 0.01). Manipulation under anaesthesia did not result in statistically significantly better Oxford Shoulder Score than early structured physiotherapy (1.05 points, 95% confidence interval –1.28 to 3.39 points; p = 0.38). No differences were deemed of clinical importance. Serious adverse events were rare but occurred in participants randomised to surgery (arthroscopic capsular release, n = 8; manipulation under anaesthesia, n = 2). There was, however, one serious adverse event in a participant who received non-trial physiotherapy. The base-case economic analysis showed that manipulation under anaesthesia was more expensive than early structured physiotherapy, with slightly better utilities. The incremental cost-effectiveness ratio for manipulation under anaesthesia was £6984 per additional quality-adjusted life-year, and this intervention was probably 86% cost-effective at the threshold of £20,000 per quality-adjusted life-year. Arthroscopic capsular release was more costly than early structured physiotherapy and manipulation under anaesthesia, with no statistically significant benefit in utilities. Participants in the qualitative study wanted early medical help and a quicker pathway to resolve their shoulder problem. Nine studies were identified from the updated systematic review, including UK FROST, of which only two could be pooled, and found that arthroscopic capsular release was more effective than physiotherapy in the long-term shoulder functioning of patients, but not to the clinically important magnitude used in UK FROST. Limitations Implementing physiotherapy to the trial standard in clinical practice might prove challenging but could avoid theatre use and post-procedural physiotherapy. There are potential confounding effects of waiting times in the trial. Conclusions None of the three interventions was clearly superior. Early structured physiotherapy with a steroid injection is an accessible and low-cost option. Manipulation under anaesthesia is the most cost-effective option. Arthroscopic capsular release carries higher risks and higher costs. Future work Evaluation in a randomised controlled trial is recommended to address the increasing popularity of hydrodilatation despite the paucity of high-quality evidence. Trial registration Current Controlled Trials ISRCTN48804508. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 71. See the NIHR Journals Library website for further project information.

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Section: Frozen Shoulder and Diabetesmentioning

confidence: 70%

Section: Characteristics Of the Trial Populationmentioning

confidence: 99%

Surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder: the UK FROST three-arm RCT

Brealey

Northgraves

Kottam

et al. 2020

Health Technol Assess

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“…Current British Elbow and Shoulder Society guidelines (2019) for the management of atraumatic shoulder instability recommend that conservative treatment in the form of predominantly an exercise-based approach should be the first line of management in this cohort. 5 This study does not provide any evidence that would warrant any change in practice. It does however generate an insight into the association between crawling and shoulder instability and therefore asking about developmental milestones as part of a comprehensive subjective assessment could help to identify type III shoulder instability.…”

Section: Implications For Clinical Practicementioning

confidence: 85%

“…Currently high-level evidence for the treatment and management of type III atraumatic shoulder instability is lacking. 4 The 2019 British Elbow and Shoulder Society guidelines 5 have recommended that conservative management should be the first line of management in this cohort; however, currently this is predominantly based on expert opinion, cohort studies and trials with short-term outcomes.…”

Section: Introductionmentioning

confidence: 99%

The association between crawling as a first mode of mobilisation and the presentation of atraumatic shoulder instability: a retrospective cohort study

2020

Self Cite

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Background and purpose To investigate if there is an association between whether an infant crawls as their first mode of mobilisation and the subsequent presentation of atraumatic shoulder instability. Patients and methods A retrospective cohort of 50 consecutive patients who had presented to a national specialist centre for shoulder instability with a diagnosis of atraumatic instability was compared with a cohort of 50 participants who did not have shoulder instability. Primary outcomes were presence of atraumatic shoulder instability and whether or not the patient crawled as their first mode of mobility. A Pearson chi-squared test was used to evaluate associations. Results There was a significant association between crawling and shoulder instability ( X2(1) ≥ 11.93, p = 0.001) with a higher prevalence of non-crawlers in the group with shoulder instability compared to the control group. Interpretation There may be an association between developmental milestones and atraumatic shoulder instability. It cannot be concluded from this study whether association is causal and additional research is needed to further investigate this relationship. Asking patients presenting with shoulder instability about their developmental milestones as part of a full subjective history could guide a more targeted sensorimotor rehabilitation programme.

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“… 3 In such cases, conservative management, such as physiotherapy rehabilitation, is recommended with surgery as the limited resort. 22 Physical therapy of patients with the loose shoulder is aimed at strengthening the rotator cuff to maximize the concavity-compression mechanism and stabilizing the scapula to stabilize the glenoid platform. The rotator cuff contributes significantly to compressive forces at the glenohumeral joint.…”

Section: Discussionmentioning

confidence: 99%

The infraspinatus muscle activity during pitching motion in baseball players with shoulder instability

Kotoshiba

Urabe

Hara³

et al. 2021

JSES International

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Background Shoulder microinstability is often overlooked, which can be problematic, especially in overhead athletes. The slipping phenomenon is defined as posterior or lateral sliding of the humeral head in an elevated arm. When the shoulder is close to the end range of stability, the infraspinatus is highly activated and keeps the shoulder in the glenoid cavity. This study aimed to examine the characteristic physical function and infraspinatus activity during the pitching motion in baseball pitchers with shoulder instability. Methods Twenty-one male baseball pitchers participated and were divided into 2 groups based on radiograph findings at zero position: slipped (group S) and nonslipped (group N) groups. Physical function using Hara test and infraspinatus muscle activity during pitching were evaluated. Results The infraspinatus muscle activity during the acceleration phase was significantly greater in group S (59.5 ± 33.0%MVC) than in group N (33.0 ± 16.9%MVC) ( P < .05). Positive rate of the Hara test in group S was significantly high in the loose test and elbow push test. Conclusions This study shows that baseball pitchers with slipping phenomenon have capsular laxity and scapular instability that indicate high infraspinatus muscle activity during the acceleration phase. Therefore, repetitive pitching with hyperactivity of the infraspinatus on the slipping shoulder may cause fatigue and dysfunction.

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BESS/BOA patient care pathways: Atraumatic shoulder instability

Cited by 16 publications

References 46 publications

Surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder: the UK FROST three-arm RCT

Surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder: the UK FROST three-arm RCT

The association between crawling as a first mode of mobilisation and the presentation of atraumatic shoulder instability: a retrospective cohort study

The infraspinatus muscle activity during pitching motion in baseball players with shoulder instability

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