Posterior Shoulder Instability Classification, Assessment, and Management: An International Delphi Study

Abstract

Objective To reach consensus among international shoulder experts on the most appropriate assessment and management strategies for posterior shoulder instability (PSI). Design Delphi. Methods In phase 1 of the study, we reviewed the literature, generated the Delphi items, created the survey, and identified clinical experts. In phase 2 of the study, clinical shoulder experts (physical therapists, orthopaedic surgeons, sports medicine physicians, and researchers) participated in a 3-round e-Delphi survey. For consensus, we required a minimum of 70% agreement per round. Descriptive statistics were used to present the characteristics of the respondents, the response rate of the experts in each round, and the consensus for PSI classification, assessment, and management. Results Round 3 was completed by 47 individuals from 5 different countries. The response rate ranged from 57/70 (81%) to 47/50 (94%) per round. Respondents agreed on 3 subgroups to define PSI: traumatic (100% agreement), microtraumatic (98% agreement), and atraumatic (98% agreement). Conclusion International shoulder experts agreed that the clinical presentation, management strategy, and outcome expectations differ for traumatic, microtraumatic, and atraumatic PSI. Their recommendations provide a framework for managing these subgroups, with additional consideration of sport and work participation and subsequent risks. J Orthop Sports Phys Ther 2020;50(7):373–380. Epub 29 Apr 2020. doi:10.2519/jospt.2020.9225

Management of atraumatic shoulder instability in physiotherapy (MASIP): a survey of physiotherapy practice

“…Management has historically been directed by expert opinion through clinical commentaries and consensus studies [ 13 , 14 , 16 ], rather than high quality evidence [ 17 , 18 ]. Some authors suggest using classification systems to help guide clinical practice to help direct management [ 7 , 8 , 19 , 20 ], which was echoed in a recent Delphi study of posterior shoulder instability [ 18 ].…”

“…Exercise-based rehabilitation is the primary approach recommended for ASI management [ 14 , 16 , 18 , 21 , 22 ]. Rehabilitation of the periscapular and rotator cuff muscles are widely recommended for ASI [ 14 , 15 , 18 , 21 , 23 , 24 ] and are specifically cited in the recently published national guidelines for managing ASI [ 17 ].…”

“…Exercise-based rehabilitation is the primary approach recommended for ASI management [ 14 , 16 , 18 , 21 , 22 ]. Rehabilitation of the periscapular and rotator cuff muscles are widely recommended for ASI [ 14 , 15 , 18 , 21 , 23 , 24 ] and are specifically cited in the recently published national guidelines for managing ASI [ 17 ]. Additionally proprioceptive exercises [ 9 , 15 , 16 , 21 , 23 , 25 ], flexibility exercises [ 9 , 18 , 21 ] and functional and sport specific training [ 9 , 16 , 18 ] are frequently highlighted.…”

“…Rehabilitation of the periscapular and rotator cuff muscles are widely recommended for ASI [ 14 , 15 , 18 , 21 , 23 , 24 ] and are specifically cited in the recently published national guidelines for managing ASI [ 17 ]. Additionally proprioceptive exercises [ 9 , 15 , 16 , 21 , 23 , 25 ], flexibility exercises [ 9 , 18 , 21 ] and functional and sport specific training [ 9 , 16 , 18 ] are frequently highlighted. The extent to which physiotherapists have adopted specific types of exercise, such as rotator cuff training, kinetic chain, or exercise-based protocols within their clinical practice when managing ASI is unknown.…”

“…It is recommended that signs of movement related fear and anxiety are addressed in the early stages of management through reassurance, education and early mobilisation [ 13 , 14 , 16 , 30 ], which reflects the importance placed on these strategies within the recently published guidelines [ 16 ]. A small number of authors also recommend the provision of suitable education for patients in order to explain the role of rehabilitation, optimise pain management, promote understanding of ASI and the general anatomy and function of the shoulder [ 13 , 18 ], as well as validation of the patient experience [ 31 ].…”