The Effectiveness of Rehabilitation for Nonoperative Management of Shoulder Instability:

A Systematic Review

Kylie Gibson, MScPT

McMaster University Chemong Physiotherapy Bridgenorth, Ontario, Canada

Angela Growse, MScPT

McMaster University Back on Track/WSIB Specialty Clinic St. Johns Rehabilitation Hospital Toronto, Ontario, Canada

Lesley Korda, MScPT

McMaster University Motion Plus Physiotherapy Guelph, Ontario, Canada

Emily Wray, MScPT

McMaster University Lifemark Health Hamilton, Ontario, Canada

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 24item 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. J HAND THER. 2004;17:229242.

Joy C. MacDermid, BScPT, PhD

School of Rehabilitation Science McMaster University Hamilton, Ontario, Canada Clinical Research Lab Hand and Upper Limb Centre St. Josephs Health Centre London, Ontario, Canada Career Scientist of the Ontario Ministry of Health Health Research Personnel Development Program

The shoulder is a multiaxial ball-and-socket synovial joint that relies on muscles and ligaments rather than bony alignment for its stability.1 Due to its anatomic structure, the shoulder allows for a large range of movement (three degrees of freedom), which therefore compromises its stability. ConseCorrespondence and reprint requests to Joy C. MacDermid, BScPT, PhD, School of Rehabilitation Science, IAHS, 1400 Main Street West, 4th Floor, Hamilton, Ontario, Canada L8S 1C7; e-mail: <macderj@mcmaster.ca>. doi:10.1197/j.jht.2004.02.010

quently, bony abnormalities, ligament laxity, and muscle imbalances can often result in and lead to further shoulder impairments and functional limitations.2 Shoulder instability is one such example, with prevalence ranges of 66% to 100% in individuals aged \20 years, 13% to 63% of those aged 20 to 40 years, and 0% to 16% of those older than 40 years.3 With such a high proportion of individuals affected, further investigation of shoulder instability is warranted to establish effective treatment strategies. The conceptual denitions of multidirectional instability and subluxation were established in 1980
AprilJune 2004 229

and have led to more accurate diagnoses of these now-recognized important clinical entities.4 The mechanism of injury for shoulder instability is most commonly a combination of abduction and external rotation beyond the joints anatomic limit.2 However, shoulder instability can also result from atraumatic events. Both traumatic and atraumatic instabilities are common in young and older adults, resulting in detrimental physical outcomes.5 Older adults tend to report limitations with activities of daily living (ADLs) secondary to shoulder instability, whereas young adults frequently report that their participation in sports is most adversely affected.6 The prognosis following an anterior shoulder dislocation in young patients (aged 1722 years) is poor, and recurrence of dislocation or subluxation has been reported to be greater than 80%, which emphasizes the importance of determining effective management of shoulder instability.7 Shoulder instability is a broad term, but for the purpose of the current review, it is dened as symptomatic hypermobility, which includes traumatic and atraumatic subluxation or dislocation resulting in single-plane or multidirectional instability. Numerous conservative treatment strategies have been reported in the literature for the treatment of traumatic and atraumatic shoulder instability, and they include: immobilization, varied strengthening methods, stabilization exercises, electromyography biofeedback, and patient education regarding avoidance of particular physical activities.916 Despite many published reviews describing such interventions, there is a paucity of denitive, empiric evidence to substantiate their effectiveness. Conservative treatment is an important rst line of treatment in affected individuals, particularly those with an isolated dislocation. Commonly, patients will undergo a trial of conservative management even when surgery is indicated in part for practical reasons and in part to reestablish the strength and mobility of the involved structures.8 The purpose of this systematic review is to determine the effectiveness of conservative management as the primary management strategy for shoulder instability. Outcomes of interest include decreasing the recurrence of instability, improving return to premorbid status, and alleviating symptoms associated with both traumatic and atraumatic shoulder instability. Additionally, this review will identify and dene the effectiveness of specic conservative management protocols.

striction 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, physical therapy, and physical therapy techniques, which resulted in 211 articles. Titles were reviewed for initial inclusion by one of the four investigators (KG, AG, LK, or EW), narrowing the count to 129 articles. Abstracts were then collected and reviewed by two investigators (KG and AG or LK and EW) to identify primary research articles and previous reviews specically addressing the research question. Where disagreement occurred, a third reviewer was used. Seventy-two complete articles were then collected and read for nal inclusion using the following criteria. 1. Type of study: Randomized, controlled trial (RCT) or quasi RCT, cohort study, and case series. 2. Type of participant: Adults (aged 1655 years) with a history of shoulder instability (subluxation or dislocation). Studies using patients with a history of prior shoulder surgery, stroke, or hemiplegia were excluded. 3. Type of intervention: Nonoperative management, including but not limited to immobilization and physical therapy techniques such as stretching, strengthening, or stabilization exercises, biofeedback, and other modalities. Studies reporting the effectiveness of surgical techniques were excluded unless they were being compared with a nonsurgical management technique. Relocation and splinting approaches were also excluded. 4. Type of outcome: Recurrence of instability (redislocation or resubluxation), return to premorbid function (work or sport), resolution of associated symptoms. Each of the study evaluators completed a trial appraisal using the critical appraisal form (effectiveness) developed by JCM (included in the introductory article17) to ensure investigator clarity on scale items. After this, the 19 articles included in the nal selection were each independently critiqued for methodological quality by two of the four reviewers. When scoring discrepancies occurred, consensus between the two reviewers was used to resolve the difference to one point and articles scoring >18 were then chosen for nal inclusion, resulting in the 14 studies included in this review.

METHODS RESULTS
A primary literature search of computerized bibliographic databases was conducted with an English-only language restriction and a date re230 JOURNAL OF HAND THERAPY

Table 1 lists the consensus scores of methodological quality for each of the 19 articles meeting the inclusion

TABLE 1. Design Elements of Studies Evaluating the Effectiveness of Rehabilitation for Nonoperative Management of Shoulder Instability Study Item
Arciero et al., 1994 Aronen et al., 198419 Bottoni et al., 200220 Burkhead et al., 199221 Fronek et al., 198922 Hurley et al., 199223 Kirkley et al., 199924 Kiss et al., 20017 Kiviluoto et al., 19808 Reid et al., 199625 Takwale et al., 200026 Tillander et al., 199827 Wheeler et al., 19895 Wintzell et al., 199928 Beall et al., 198729 Gross et al., 199330 Moreau et al., 200131 Sonnabend, 199432 Young, 199433
18

Design 1
1 1 2 2 2 1 2 2 2 1 2 2 1 1 0 1 2 1 2

Subjects 6
0 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 0 1 1

Intervention 14
1 1 0 0 1 0 2 0 0 0 1 1 0 1 0 1 1 1 1

Outcomes

Analysis

2
2 0 2 0 2 2 2 0 2 2 0 2 2 2 0 0 0 1 0

3
1 1 2 1 1 0 2 2 1 2 1 1 2 1 1 1 1 0 1

4
1 1 2 1 1 0 2 1 1 2 2 0 2 2 1 1 2 1 1

5
0 0 2 0 0 0 1 0 0 1 0 0 1 2 0 0 0 0 0

7
1 1 1 0 1 1 1 0 0 1 0 1 1 1 1 1 0 1 0

8
0 0 0 0 0 1 1 0 1 0 1 1 0 1 0 0 0 0 0

9
2 0 1 1 1 1 2 1 1 1 1 2 1 1 0 0 0 1 0

10 11 12 13
2 1 2 0 1 0 2 0 1 1 1 1 1 2 1 0 0 0 0 0 1 0 0 0 0 2 0 0 0 0 0 0 1 0 0 0 1 0 2 2 1 2 1 1 2 1 0 0 2 1 0 2 2 2 2 2 2 1 2 1 2 2 1 2 1 1 1 2 1 1 1 2 1 2 1 2

15
2 0 2 0 2 2 2 0 2 1 0 2 1 2 0 1 0 0 0

16 17 18 19 20 21 22 23 24 Total
1 1 1 1 1 1 2 1 1 1 1 1 1 1 0 1 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1 1 0 1 1 0 0 1 2 2 2 1 2 2 1 1 2 1 1 2 2 1 0 2 1 2 1 0 1 0 0 1 1 1 1 1 0 1 1 2 0 0 0 0 0 0 0 1 0 0 0 2 1 0 0 1 0 0 0 0 0 0 0 0 1 0 1 1 0 1 1 1 1 1 0 0 1 2 0 0 0 0 0 1 2 0 1 0 0 2 1 0 0 1 0 0 1 2 1 0 0 0 1 1 1 1 2 1 1 1 1 1 0 1 1 1 1 1 1 1 1 2 2 2 2 1 1 2 1 1 2 1 1 2 2 1 1 2 1 2 25 21 30 19 22 19 41 18 20 23 19 22 23 33 14 15 17 15 16

This table describes the design elements for 24 specic aspects of research design for the studies appraised. A score of 2 represents the best score and indicates a high-quality approach to this element of research design. A score of 1 indicates only fair quality of research design or the criteria were only partially met, and a 0 indicates poor quality or the criteria were unfullled. The specic descriptors of these levels are included in the introductory article.

criteria. Table 1 describes 24 specic 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 criteria. Specic descriptors of these levels can be found in the introductory article in this issue.17 After methodological scoring of all articles, a score of 18 out of a possible 48 was determined as a conservative inclusion threshold based on the range of quality scores of the 19 articles included for methodological review. A score of 18 implies that, on average, over 75% of the scoring criteria had a score of at least 1 on a scale of 0 to 2, indicating that the criteria were somewhat met. Common methodological weaknesses of the studies include failure to randomize subjects, failure to include a control group, failure to blind treatment providers or assessors, and failure to conduct statistical analyses. Table 2 summarizes the 14 studies scoring >18 and can be referred to for more specic support of the following results and recommendations. The following categories: patient descriptors, interventions used, outcome measures or evaluations recorded, study results, result modiers such as patients lost to follow-up or recovery complications, and Sacketts level of evidence and study type, have been used to present important aspects of the research articles. Results were analyzed for the effectiveness of each type of intervention to change patient outcomes of:

(1) recurrence of instability (redislocation or resubluxation), (2) return to premorbid function (work or sport), and (3) resolution of symptoms.

Immobilization with General Strengthening or Stabilization Exercises

Recurrence of Instability Six studies examined the effectiveness of conservative management for decreasing recurrence of instability after primary shoulder dislocation. A single low-quality RCT of 99 subjects under 50 years of age reported recurrence at one year of follow-up to be 17% in those subjects immobilized for three weeks versus 26% in those immobilized for only one week.8 Of the total dislocations in both groups, 63% occurred in individuals under 30 years of age (p \ 0.001). Two smaller trials of 24 and 36 subjects found that 75% and 80% of conservatively managed subjects with traumatic dislocation and instability, respectively, had redislocated within an average follow-up of 36 and 23 months.19,21 Comparatively, only 11% and 14% of the surgically treated subjects redislocated, respectively. Neither study described a well-dened rehabilitation protocol; however, rehabilitation was reportedly supervised. A single cohort study of 20 highly active naval academy personnel aged 18 to 22 years used a protocol of three weeks immobilization in a sling followed by restricted activity and a moderately
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TABLE 2. Characteristics and Outcomes of Included Studies

Evidence of Treatment Effects for Nonoperative Management of Shoulder Instability Study Author Journal, Year Patients Number & sex of patients, mean age (range), patients description, type of instability, group description Interventions Group (number of patients), Rx type, duration, frequency, intensity, follow-up duration Evaluations Type, timing Results Modiers Level According to Sackett et al., 2000, study type

Within group, between Percentage lost to group: absolute changes, follow up, reasons, p values (if available) any complications, for all outcomes, RTW factors affecting if noted time to RTW, nonresponse

Level 2b, Percent lost to Within Group: individual follow-up: 0 Recurrence: prospective Complications: 3 Group I80% (12/15) cohort postoperative Group II14% (3/21) complications Function: no data (abscess resolved Symptoms: Group I13% (2/15) excellent, 6% (1/15) with antibiotics, median nerve good, 80% (12/15) poor hyperesthesia Group II76% (16/21) resolved in 3 wks) excellent, 10% (2/21) good, 14% (3/21) poor Between Group: Recurrence: increased rate of recurrent instability in group I (p = 0.001) Symptoms: N/A Additional Outcomes Time to recurrence: 10 mos (516) for group I vs. 16 mos (924) for group II Level 4, Percent lost to Within Group: Aronen et al. Recurrence of Treatment for all patients N = 20 M = 20, poor- quality follow-up: 0 (Am J Sports instability: dislocation Recurrences: 15% (3/20) 3 wks immobilization in W = 0 Age = 19.2 19 retrospective Complications: none dislocation (at 6 mos), Med, 1984) or subluxation sling, oral analgesics, and (1822) Case series reported 10% (2/20) subluxation restricted activity, followed Return to premorbid All Naval Academy (at 13, 36 mos) function: by 23 wks day use of midshipmen Function 3 mos (2.54 mos) unrestricted activity sling, followed by 6 (410) All primary shoulder Symptoms: no data wks rehab ex and routine Return of symptoms: dislocations Between Group: N/A activities and sports No comparison group *Rehab exercises progressed Additional outcomes: Achievement of goals Additional Outcomes: from isometrics of int rot Goal Achievement: 75% & abd in neutral (8-sec hold, (no evidence of success weakness or atrophy, 2-sec rest) apprehensive-free, To isotonics with thera-band return to full active, To isokinetics on Cybex unrestricted duty & (40 sec X 2 with athletic participation) 35 min rest between) Timing: 6, 13, 36 months To isokinetics in the apprehension position for Follow-up: 35..8 mos (1745 mos) all shoulder movements To isotonics with free weights & machines *repetitions & sets determined by discomfort experienced (frequency undened) Bottoni et al. Percent lost to follow- Level 2b, Within Group: Recurrence of N = 24 M = 24, W = 0 Group 1 (14): 4 wks (Am J Sports up: 12.5% within rst low -quality instability: dislocation, Recurrence: Group I: 75% immobilization plus Age = 22.4 (1826) Med, 2002)20 All active duty military prospective (9/12) Group II: 11% (1/9) 24 mos, but all 3 had symptomatic isometrics and Codmans RCT already experienced subluxation/instability Function: all patients Ex, followed by a 12-wk, personnel recurrence of returned at mos preventing RTW but 3-phase therapistAll primary traumatic instability not requiring surgery Symptoms: no data supervised rehab program dislocation, with no Complications: none Between Group: No data Return of symptoms: history of previous 1) PROM/AAROM, no reported Additional Outcomes: N/A resistance shoulder injury, ROM: no sign diff at 6 Return to premorbid 2) Full AROM with fracture, or nerve months between group I function: return to increasing resistance injury and group II full active duty and 3) Continued use, SANE: Group I57 (4698) contact sports strengthening, return to Group II88 (60100) Additional outcomes: active duty and contact (p = 0.002) ROM, SANE score, sports at 4 mos LInslata Score: LInsalata shoulder Group I73 (4692) evaluation, patient Group II (10): arthroscopic Group II94 (6598) satisfaction stabilization, followed by (p = 0.002) Timing: weekly for 8 4 wks immobilization, Patient satisfaction: weeks, then monthly followed by group Is Group I25% (3/12) for 4 weeks, then conservative Rx excellent, 75% (9/12) poor biannually in person, (immobilization, rehab) Group II60% (6/10) or by phone if excellent, 20% (2/10) unavailable good, 10% (1/10) poor Follow-up: 36 months (1656) Recurrence of instability: Poor result dened as recurrent instability, subluxation or dislocation Return to premorbid function: N/A Return of symptoms: Rowe scale Additional Outcomes: Time to recurrence average Timing: not reported Follow-up: Group I23 mos (1539) Group II32 mos (1545) (continued)

N = 36 M = 36, W = 0 Group I (15): 4 wks Arciero et al. immobilization, followed Age = 20 (1824) (Am J Sports Med, 1994)18 All patients were athletic by 4 mos of an undened supervised rehab program, military cadets with and (gradual) return to no history of activity subluxation or impingement Group II (21): Bankart All acute primary surgical repair within 10 traumatic anterior days of dislocation then, followed by group Is dislocation requiring conservative management manual reduction, (4 wks immobilization none with then rehab) concomitant nerve injury *patients self-selected Rx

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TABLE 2. (continued) Evidence of Treatment Effects for Nonoperative Management of Shoulder Instability
Study Patients Interventions Evaluations Recurrence of instability: N/A Return to premorbid function: Rowe and Zarins score Return of symptoms *type not specied Timing: every 68 weeks Follow-up: 34 mos Results Modiers Percent lost to follow up: not reported, even though incomplete data reported Complications: none reported Level Level 4, case series

Group I (37): subluxation Burkhead et al. N = 115 M = 82, with no prior dislocation (J Bone Joint W = 33 Age = 24.6 Group II (31): subluxation Surg [Am], Mixed traumatic and with history of dislocation 1992)21 atraumatic, Group III (5): atraumatic subluxations with and without previous subluxation with psych issues dislocation; some Group IV (10): subluxation with psych issues without psych issues Group V (32): involuntary subluxation *Rx for all patients 2-phase rehab program: 1) 5 progressive - resistance strength Ex for deltoids and RTC using thera-band (30 3 59), 5-sec hold 3 5 repetitions 3 3, daily 2) Continuation of phase 1, using 810 lb weights on a pulley system *Rx duration undened *Psych Rx for patients with psych issues at mos 34 if no improvement Fronek et al. N = 24 M = 19, W = 5 Group I (16 patients with (J Bone Joint moderate disability with Age = 20 (1145) Surg [Am], ADLs): supervised PT All posterior instability, 1989)22 program emphasis on mixed traumatic and RTC (external rotator) atraumatic strength, progressions of *3 patients active in active internal and collegiate sports had external rotation with increased pain and shoulder less than 458 arthroscopic ABD using springs and debridement before free weights, followed PT program by home program Group II (8 patients with incapacitating symptoms when involved in strenuous exercise and substantial disability with ADLs + 2 from group I who were unsuccessful with treatment): posterior capsulography *Rx duration undened

Within Group: Recurrence: no data Function Recurrence: no data Function: Group I23% (9/40) good/excellent, 77% (31/40) fair/poor Group II9% (3/34) good/excellent, 91% (31/34) fair/poor Group III40% (2/5) good/excellent, 60% (3/5) fair/poor Group IV88% (14/16) good/excellent, 12% (2/16) fair/poor Group V87% (39/45) good/excellent, 13% (6/45) fair/poor Symptoms: trend for symptoms to return if Ex were discontinued *often in teenagers Between Groups: no data Additional Outcomes: none Within Group: Recurrence of Recurrence: Group23% instability: patient (3/13) failures and rated disability 0 85% (11/13) some (worst)3 (best) degree of persistent Return to premorbid function: level of instability participation in sports Group II0% failure on 3 point scale Function: Return of symptoms Group I46% (6/13) returned to sport NPRS (03;worstbest) Timing: not reported or strenuous activities with or without Follow-up: not reported limitations Group II91% (10/11) improved ability to participate in sports or strenuous activities *70% of these patients at a diminished level of competition Symptoms: Group I77% (10/13) diminished pain, more stability, or both Group II82% (9/11) diminished pain postop Between Group: Recurrence: decreased instability for group II (p \ 0.05) Symptoms: increased improvement in pain rating group II (p \ 0.05) Function: increased sports participation trend for group II

Percent lost to follow-up: 4% (1/24) Complications: 1 patient from group I developed a supercial infection developed

Level 4, poor quality cohort

(continued on next page)

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TABLE 2. (continued) Evidence of Treatment Effects for Nonoperative Management of Shoulder Instability
Study Patients Interventions Evaluations Recurrence of instability: interview & clinical examination (not specied) Return to premorbid function: return to sports Return of symptoms: subjective report Additional outcomes: internal/external shoulder rotation strength Timing: not reported Follow-up: Group I: 4.8 yrs (210) Group II: 5 yrs (211) Results Modiers Level

Hurley et al. N = 50 M = 34, W = 13 Group I (25): supervised progressive rehab (Am J Sports Age: 17.3 (1030) program emphasis on Med, 1992)23 All posterior instability RTC (external rotator) due to direct or strength, 23 sets per minor repetitive Ex, 3 3 /wk trauma Group II (25 with continued instability following the rehab program): surgical correction within 17 mos (3 mos6 yrs), most with reverse Putti-Platt procedure, postop in a neutral rotation spica cast for 68 wks, followed by ROM, and the above rehab

Recurrence of Kirkley et al. N = 40 M = 35, W = 5 Group I (21): 3 wks instability: (Arthroscopy, immobilization, 2 wks Age = 22.4 (1630) redislocation 1999)24 AAROM, external rotation Skeletally mature 208 past neutral, pendular Return to premorbid patients from function: 100 mm exercises, scapular emergency room and VAS scale for: limited retractions 2 wks AROM, orthopedic centers All primary shoulder isometrics, external rotation participation in sports/recreation and limited 458 past neutral, dislocations ability to perform scapular exercises/ sport skills affected? retraining 4 wks AROM Return of symptoms: with terminal stretch, ROM (goniometry) isotonics, scapular Additional outcomes: strengthening 4 wks disease-specic QOL noncontact & nonoverhead (WOSI) sports, return to work Timing: 0 and 24 mos *return to contact sports Follow-up: 24 mos at 4 mos Group II (19): stabilization Sx (trans-glenoid suturing) within 4 wks of dislocation followed by the above Rx duration: 4 mos

Level 4, poor Within Group: Percent lost to quality Recurrence: follow-up: Retrospective Group I: 96% (24/25) 6% (3/50) unable to cohort Group II: 76% (19/25) contact, all in Function: group II Group I20% Adverse effects: (5/25) full sports, 24% N/A (6/25) return to less desirable level, 52% (13/25) limited return/no overhead, 4% (1/25) gave up sports Group II4% (1/25) full sports, 12% (3/25) return to less desirable level, 48% (12/25) limited return/no overhead, 24% (6/25) gave up sports Symptoms: Group I: 68% (17/25) improved, 4% (1/25) reported instability Group II: 55% (12/22) improved, 50% (6/12) no further instability Between Groups: Recurrence: no sign diff Symptoms: no sign diff Additional outcomes: Strength: no sign diff involved shoulder vs. uninvolved in those satised with treatment Level 1b, Percent lost to Within Group: individual follow-up: 0 Recurrence: RCT Complications: Group I: 47% (10/24) 1 patient developed Group II: 15.9% (3/19) postop joint sepsis Function: in group II Group I27.77, 30.69 Group II7.95, 10.81 Symptoms: Group Iex 99.47 6 5.73, external rotation at side 99.74 6 23.74, external rotation at 908 96.14 6 14.53, internal rotation at 908 94.28 6 20.39 Group IIex 94.91 6 8.02, external rotation at side 87.03 6 27.48, external rotation at 908 92.90 6 24.83, internal rotation at 908 98.34 6 16.62 Between Groups: Recurrence: increased rate of redislocation in group I vs. group II (p \ 0.03) Function: increased sport and recreation limitation in group I vs. group II (p \ 0.05) Symptoms: no sign diff, trend of increased limitation of external rotation in group II Additional Outcomes: QOL: worse QOL (domains & total score) for group I (287.1 vs. 633.93, p \ 0.03) *WOSI indicated that patients in group I who did not redislocate still had a decit in shoulder function (continued)

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TABLE 2. (continued) Evidence of Treatment Effects for Nonoperative Management of Shoulder Instability
Study Kiss et al. (Int Orthop, 2001)7 Patients Interventions Evaluations Results Modiers Level Level 4, poor-quality prospective cohort

Within Group: Percent lost to follow Recurrences: group I34% up: 13% (1 death, 8 (21/62 shoulders) had moved) Complications: none positive tests Group II54% (12/22 shoulders) reported had positive tests Function: Group I: 61% (38/62 shoulders) had mild or no disability, 15% (9/62) had moderate disability, 24% (15/62) had severe or total disability Group II: 27% (6/22) had mild or no disability, 18% (4/22) had moderate disability, 55% (12/22) had total disability Symptoms: no data Between Group: Recurrence: increased rate of persistent instability for group II (p \ 0.05) Function: poorer function for group II (p \ 0.001) Symptoms: no data *4 shoulders in group I elected to have surgery following unsuccessful Rx and 7 in group II required further Rx Percent lost to Within Group: Kiviluoto et al. N = 226 M = 126, Recurrence of Group I (53 patients, follow-up: 0 Recurrence: (Acta Orthop instability: \50 yrs of age): W = 100 8 Complications: none Group I: 26% (14/53) Scand, 1980) Age = (1686) 97 redislocation immobilization in reported Group II: 17% (8/46) Return to premorbid mitella, 1 week manual labourers, Group III: no relevant data function: RTW Group II (46 patients, 17 retired persons, as subjects beyond age (number of sick \50 yrs of age): complete 13 students, 45 ofce range of interest Total: days taken) immobilization in workers All primary 13% (30/226, 23 M, 7 W). Return of symptoms: shoulder dislocations, stockinette-Gilchrist 56% (30/53) of group I vs. not assessed bandage, 3 wks some with 22% (10/46) of group II Timing: Follow-up: Group III (127 pts over complications at Function: 1 year 50 yrs of age): initial injury Group I2.8 wks, immobilization in mitella, Group II3.8 wks, 1 wk secondary to Group III3.9 wks proposed intolerance Symptoms: no data to 3 week immobilization. Between Group: *Postimmobilization (all Recurrence: not reported patients): encouraged to use Function: group I took less the shoulder, PT mobs for sick days than group II any difculties and III (p \ 0.01) Reid et al. Percent lost to follow Within Group: Recurrence of N = 20 M = 20, W = 0 Group I (11): isokinetic (Physiotherapy Age = (1826) All up: 40%, due to 2 Recurrence: no data instability: N/A resistance exercises, Canada, frank traumatic Function: Group I: 0 vs. 5 Return to premorbid 2 3 /wk, 3 sets of 10 male university 1996)25 scored moderate limitation dislocations, 1 did function: Modied at 60, 90, 120, 150, athletes (hockey, at work and 5 vs. 11 at sport not want to version of Constant & & 1808/sec, with 90-sec football, swimming, participate, 4 could when comparing 52 wks Murleys scale (work, basketball, volleyball, rest between sets not be reached or vs. baseline but neither sport, ADL) racquetball, baseball, Group II (9): visual & Return of symptoms: pain were of sign diff Group II: moved auditory biofeedback of tennis) All improved work function Complications: none at rest & with activity rotator cuff contraction symptomatic reported using a verbal response at 8 wks (p \ 0.05), sport during a functional subluxing shoulders function at 52 wks scale (none, moderate, endurance program, (p \ 0.05) severe) 2 3 /week Symptoms: *both groups received educ Additional outcomes: Group I: no sign change isokinetic strength of posture, pain avoidance, Group II: decreased pain at using Cybex (abd, activity modication 26 and 52 wks (p \ 0.05) add, internal rotation, Rx duration undened Between Group: external rotation in Function: no sign diff neutral and apprehension position) Symptoms: no sign diff Additional outcomes: at 608 & 1808/sec Strength: Group I: increase in Timing: 0, 8, 26, abd & rot torques 52 weeks (p \ 0.05) Group II: Follow-up: 1 year increased abd and int rot torque at 52 wks (p \ 0.05)

Recurrence of instability: N = 68 (84 symptomatic Group I (62 shoulders) battery of tests of Group II (22 shoulders with shoulders) M = 24, instability (dislocation/ previous surgery) W = 37 Age = 28.4 subluxation on active *Rx for all patients Rehab (16.748) program: patient education, elevation, ant/post All traumatic shoulder apprehension, ant/post movement retraining for dislocations, 25 drawer, sulcus sign, scapulothoracic and bilateral, 47 pseudowinging of glenohumeral joints using shoulders scapula) mirrors, PNF, biofeedback, posteroinferior, stability training using Return to premorbid 11 multidirectional strengthening Ex, closed function: Constant and Rowe score, and chain Ex, and stamina training, occupational subjective shoulder therapy and home exercise rating programs (frequency and Return of symptoms: N/A duration undened) Additional outcomes: none Timing: not reported Follow-up: 3.7 yrs

Level 2b, individual prospective cohort

Level 2b, low-quality RCT

(continued on next page)

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TABLE 2. (continued) Evidence of Treatment Effects for Nonoperative Management of Shoulder Instability
Study Takwale et al. (J Bone Joint Surg [Br], 2000)26 Patients N = 50 M = 21, W = 29 Age = 17.3 (932) Patient descriptors Atraumatic dislocation or subluxation, 39 posterior, 22 had a voluntary component Interventions Evaluations Results Modiers Level Level 4, case series

Percent lost to Recurrence of instability: Within Group: Rx for all patients: follow-up = 0 N/A Recurrence: no data 2-phase PT program Complications: none Return to premorbid Function: 62% (31/50) 1. Visual analysis of the reported function: examiners excellent, 42% (21/50) abnormal muscle patterns grading, excellent (no good, 12% (6/50) poor 2. Individualized scapular symptoms and no Symptoms: 2% (1/50) none, retraining emphasizing activity restriction), 92% (46/50) pain, 94% underactive patterns good (some symptom, (47/50) dysfunction, 40% (elevation, depression, no activity restriction), (20/50) clicking, 12% retraction, protraction) (6/50) locking, 22% poor (activity Progression from eccentric restriction) (11/50) other to concentric, Return of symptoms: *trend toward improved 34 sessions on each of the relapse of abnormal VAS for all patients rst two days, then daily, movement pattern Between Group: no neutral ABD initially, comparison group and VAS shoulder progressed to 908AAROM rating 0 (bad as it Additional outcomes: *hydrotherapy for 7 patients Time to establish normal could be), Rx duration undened muscle control: 2.7 days 10 (normal) (0.510 days) Additional outcomes: Time to establish muscle control Timing: undened Follow-up: 2 yrs (avg) Tillander et al. N = 32 M = 13, W = 19 Group I (6, main symptom Percent lost to Recurrence of instability: Within Group: (Scand J Med follow-up: 0 Recurrence: those requiring Sx Age = (1652) of pain, no instability): Sci Sports, Complications: none Group I: 66% (4/6) following rehab or Voluntary and rehab Ex program 27 1998) reported Group II: 17% (1/6) persistent instability involuntary Group II (6, main symptom Group III: 55% (11/20) Return to premorbid dislocations (3 with instability): early Sx, Group IV: 13% (1/8) function: previous surgical inferior capsular shift, Function: Constant and Rowe repair) 3 wks immobilization, Group I: no major change in scores, change in 3 wks night splint only activity level Group III (20, main symptom activity level (yes/no) Group II: no major change in Symptoms: undened instability): rehab Ex (reported for one group activity level -Constant program avg: 69 -Rowe avg: 65 only) Group IV (8, main symptom Group III: no data Additional outcome: instability): rehab Ex Group IV: 37% (3/8) patient satisfaction program, then Sx following Rx (yes/no), *trend of increased activity *Rehab Ex: 6 weeks RTC and (sports) ROM for surgical scapular stabilizers Symptoms: patients neuromuscular training in Group III: decreased Timing: safe, painfree ROM, Constant avg: 82 -Rowe between 953 mos then 8 weeks with avg: 55 Between Group: Follow-up: undened additional painfree arm Function: better Rowe score elevation, for group IV pt vs. group then 6 wks overhead and III (p = 0.0156) functional exercise, full Additional outcomes: Pt ROM, PNF satisfaction: *gradual return to full Group I: 0/6 satised activity at wk 21 (Rx Group II: 83% (5/6) frequency and duration Group III: 45% (9/20) undened) Group IV: 87% (7/8) *more group II patients satised (p = 0.0302) ROM: Group II3 pts lost 15258 ex and abd Wheeler et al. N = 47 M = 46, W = 1 Group I (38): 3 wks Within Group: Percent lost to Recurrence of (Arthroscopy, Recurrence: follow-up: 0 instability: Age = 18.8 (1722) immobilization, undened 5 1989) Group I: 92% (35/38) Adverse effects: All patients were young PT, no contact or overhead dislocation or Group II: 22% (2/9) N/A subluxation athletic military sports for 3 mos Function: no data Return to premorbid cadets All primary Group II (9): ant. glenoid Symptoms: no data Between function: N/A shoulder dislocations abrasion, detached labrum Groups debrided & stapled, postop Return of symptoms: Recurrence: decreased rate for N/A Rx as above Rx duration group II (p \ 0.01) and frequency undened Additional outcomes: *Poor compliance to N/A nonop Rx, but no Timing/follow up: signicant effect on 14 mos post-Rx recurrence rates (p \ 0.01)

Level 4, poor -quality retrospective cohort

Level 4, poorquality cohort

(continued)

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TABLE 2. (continued) Evidence of Treatment Effects for Nonoperative Management of Shoulder Instability
Study Wintzell et al. (J Shoulder Elbow Surg, 1999)28 Patients Interventions Evaluations Results Modiers Level

Recurrence of instability: N = 30 M = 26, W = 4 Group I Redislocation (15): Undened nonop Rx, Age = 24 (1830) Return to premorbid encouraged to move Manual laborers and function: Constant/ shoulder freely with an white-collar workers, Murley score Rowe optional sling allowed 75% active in sports score VAS for effect All traumatic primary during the rst week on work, sports, posttrauma anterior shoulder leisure Group II dislocation, no (15): Arthroscopic lavage, 7 Return of symptoms: history of shoulder N/A days posttrauma problems Additional outcomes: post Rx Sx Timing: Group Iunknown Group II7 days post trauma Follow-up: 2 years

Level 2b Within Group: Percent lost to individual Recurrence: group I: 60% follow up: all 30 prospective (9/15) group II: 20% patients were cohort study (3/15) available for Function: examination, Group I: 73% although 3 patients (11/15) scored 87, with in the control group fair-poor outcome, VAS had undergone activity scores (2,6,1) stabilizing surgery Group II: 40% (6/15) scored and were therefore not examined 91 with fair/poor outcome, VAS activity scores (1,4,3) Symptoms: no data Between Group: Recurrence: increased rate in group I (p = 0.03) Function: no sign diff (p = 0.07) *Average age for dislocations was 23 years in both groups Additional outcomes: Post Rx Sx: group I: 40% (6/15) group II: 13% (2/15) *more group I required further Sx (p = 0.11)

Signicant difference if p \ 0.05. M, men; W, women; Rx, treatment; RTW, return to work; RCT, randomized, control trial; n/a, not assessed; Ex, exercise; PT, physiotherapy; mobs, mobilizations; sign diff, signicant difference; psych, psychological; RTC, rotator cuff; ADLs, activities of daily living; abd, abduction; rot, rotation.

dened progressive strengthening program.20 Recurrence during follow-up was reported to be much lower than commonly reported, with only 15% redislocating by six months and 10% experiencing subluxation at 13 and 36 months after return to full active military duty. In a similar poor-quality cohort study of military cadets, a 92% recurrence rate was reported among 38 cadets choosing conservative management as compared with 22% of nine cadets opting for surgical intervention.5 Again, the conservative rehabilitation protocol was not well described. A recent high-quality RCT of 40 subjects compared the outcomes of a rehabilitation protocol implemented either after injury or after stabilization surgery.25 The rehabilitation protocol consisted of three weeks immobilization followed by a detailed 12-week range-of-motion and strengthening program. At 24 months of follow-up, the study reported a 47% recurrence in those who began the rehabilitation protocol immediately postinjury versus 16% in the surgically managed group who began the protocol postoperatively, (p \ 0.03).25 This high-quality RCT conrms the ndings of a previous low-quality cohort study, which also found that a rehabilitation program after surgery resulted in fewer recurrences of instability (p \ 0.01).5

Return to Premorbid Status In two trials involving military subjects, a protocol of three weeks of immobilization followed by progressive strengthening was effective for returning subjects to full active military duty at four months posttraumatic dislocation.19,21 However, at an average follow-up of 23 to 36 months, conservatively managed subjects rated their overall outcomes signicantly worse than the surgical comparison group. Only 25% and 20% of conservatively managed subjects rated outcomes as excellent or good versus 89% and 80% of surgical subjects, respectively.19,21 In a similar trial with naval academy midshipmen subjects, three weeks of immobilization in a sling with restricted activity followed by progressive shoulder strengthening was effective for return to unrestricted activity at four months.19 All subjects were able to return to full active duty initially, although some experienced recurrence during follow-up.20 In a single larger trial examining one week versus three weeks of immobilization, those immobilized for only one week had overall fewer weeks lost from work during rehabilitation (p = 0.01).8 Unfortunately, however, the functional outcomes for subjects being immobilized for only one week were signicantly poorer.8
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Stabilization Exercises Only

Recurrence of Instability Two studies examined the recurrence of instability following conservative management consisting of stabilization exercises only, and both reported poor outcomes and high recurrence rates. In one poorquality cohort study that grouped subjects according to symptom severity, 13 subjects with moderate disability had a 23% failure rate after a protocol of rotator cuff and shoulder external rotator muscle exercises, while 83% of the subjects reported some persistent instability.23 The second study, a poorquality retrospective study of 50 subjects, reported 96% of those treated conservatively had recurrent instability at an average follow-up of 4.8 years, whereas those who underwent surgical management (primarily Putti-Platt procedures) also had a high recurrence rate of 76%.24 In both studies, all subjects had posterior instability. Return to Premorbid Status Both of the trials that assessed return to premorbid status presented weak evidence to support the use of only scapular stabilization exercises for subjects with atraumatic shoulder instability. Each protocol required subjects to complete a daily routine of exercise; however, the details of the protocol were limited, and the duration of the program was undened, making reproducibility poor.22,27 One study examined a deltoid and rotator cuff muscle strengthening protocol in 115 subjects with both traumatic and atraumatic instability, and found that subjects with traumatic and/or anterior instability did not have successful outcomes.22 Return of Symptoms Two trials of low methodological quality examined the effectiveness of stabilization exercises for alleviating or minimizing the return of symptoms. One study demonstrated that progressive strengthening of the rotator cuff muscles (emphasizing the external rotators) effectively decreased reports of pain and instability in 77% of patients with moderate disability secondary to posterior shoulder instability.23 The same high rate of improvement was not seen in the more severely disabled comparison group.23 The second study compared subjects who had undergone conservative management for posterior instability with subjects who underwent surgical intervention following a failed attempt to correct the instability using conservative management.24 Results showed 68% of conservatively managed subjects subjectively reporting improvement at a follow-up of
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4.8 years versus only 52% in surgically managed subjects at an average follow-up of ve years.24

Multimodal Intervention or Undened Protocol

Recurrence of Instability Two studies reported the efcacy of a multimodal or an undened protocol versus surgical treatment to decrease the recurrence of instability.7,29 In one lowquality prospective cohort study, only 16% of subjects being managed with a multimodal approach reported experiencing either a dislocation or subluxation within the 3.7 years of follow-up as compared with 41% of subjects who had undergone previous surgery (p \ 0.05).7 In contrast, a higherquality prospective cohort study found 60% of subjects managed with an undened nonoperative protocol had redislocated at the two-year follow-up compared with only 20% of surgical subjects (arthroscopic lavage) (p = 0.03).29 Return to Premorbid Status A single large prospective cohort trial examined a multimodal conservative management protocol and assessed its efcacy for treating multidirectional instability.7 The multimodal protocol consisted of proprioceptive neuromuscular facilitation (PNF) patterning, biofeedback, and strengthening exercises for the scapulothoracic and glenohumeral muscles in subjects with symptomatic shoulders. The subjects were evaluated in two groups: 22 subjects who had previously undergone shoulder surgery and 62 subjects who had no history of shoulder surgery. Results of the nonsurgical subjects included: 61% having mild or no disability, 15% having moderate disability, and 24% having severe or total disability.7 In those subjects with previous surgery, 27% had mild or no disability, 18% had moderate disability, and 55% had total disability.7 Between-group differences were signicant (p \ 0.001) for both raw scores and age- and gender-adjusted Constant scores. Similarly, Rowe scores also demonstrated proportionally higher ratings of fair or poor function among subjects with previous shoulder surgery compared with nonoperative subjects (p \ 0.01).7 A second good-quality prospective cohort study comparing the return to premorbid status of patients who had received surgical treatment versus conservative management found no signicant difference in outcomes measured (p = 0.07).29 However, direct comparison of the values of these two approaches is difcult due to the fact the second study29 did not dene its rehabilitation protocol in sufcient detail such that others might be able to implement it.

Return of Symptoms A single large prospective cohort trial found that a multimodal rehabilitation protocol was more effective for minimizing the severity or preventing the return of symptoms for subjects with multidirectional shoulder instability who had not received previous shoulder surgery than for those who had a history of shoulder surgery (p \ 0.05).7 The study found 61% of nonoperative subjects rated their shoulders as cured or better, whereas 37% rated their shoulders as the same as measured by patient selfassessment.7 Only one shoulder was rated as worse after treatment. Meanwhile, in the group who had a history of previous shoulder surgery, only 45% rated themselves as cured or better, whereas another 45% (ten of 22) remained the same, and the remaining 9% rated themselves as worse.7

than arthroscopic surgery followed by the same protocol for improving quality of life.24

Patient Satisfaction
One low-quality retrospective cohort that qualied for inclusion of the review included a subjective report of whether patients were satised following their treatment.28 The study of 32 subjects demonstrated that fewer patients who were treated with a rehabilitation exercise program for their shoulder instability were satised in groups who received either early surgery or surgery after failed conservative rehabilitation (p = 0.03).28

REVIEWERS CONCLUSIONS AND RECOMMENDATIONS

Although there are numerous protocols for the conservative management of traumatic or atraumatic shoulder instability published in scientic journals, the majority are based only on physiological rationale and biological evidence rather than on specic clinical trials. This reects 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 critical appraisal form was used in recognition of this paucity as it was felt important to include any potentially useful evidence. However, quality assessment in this review was often hampered by insufcient information reported concerning subject selection criteria, trial validity, treatment parameters, and standardized outcome measures. The poor reporting of the research trials thereby prevented the calculation of success rates and effect sizes and limited the review to qualitative conclusions. Unfortunately, these studies provide a weak foundation on which future clinical research studies can build as investigators will be unable to replicate interventions that have shown promise or identify potential decits that could be enhanced. Results from the 14 studies included in this review show a weak but positive trend for conservative treatment programs for managing shoulder instability. Specically, positive effects were noted with respect to decreasing the recurrence of instability, promoting the return to premorbid work or sport activity status, and decreasing or resolving symptoms associated with instability. Although weak, the trend was best supported by a program of immobilization for three to four weeks followed by a 12week program of range-of-motion and glenohumeral and scapular stabilization exercises. Although the evidence to date is insufcient to strongly support the use of EMG biofeedback alone to increase
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Electromyography Biofeedback
Return to Premorbid Status A single small randomized controlled trial of 20 subjects demonstrated that visual and auditory electromyography (EMG) feedback of rotator cuff muscle contraction during a functional endurance program twice weekly is more effective than an isokinetic resistance exercise program of the same frequency for improving function at work and in sport (p \ 0.05).26 The results were signicant at eight and 52 weeks of follow-up as measured by the modied version of Constant and Murleys scale.26 Return of Symptoms The same RCT also demonstrated that the EMG feedback group reported signicantly decreased pain at rest and with activity when compared with baseline scores (p\0.05).26 These results were significant at 26 and 52 weeks follow-up as measured by a verbal response scale, whereas the comparison isokinetic exercise group showed so signicant change at any time during follow-up.26

ADDITIONAL OUTCOMES OF INTEREST

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

shoulder stability, the results of one low-quality RCT do suggest it may be a benecial adjunct to conservative management programs.29,33 Most of the trials examining effective treatment of shoulder instability used a cohort study design to either retrospectively or prospectively compare the outcomes of interest between subjects being managed conservatively and subjects choosing surgical management. These results consistently demonstrated poorer outcomes after conservative management than with surgical management, particularly in individuals 30 years of age and younger.

DISCUSSION
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 sufcient 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 tool, which was not specically formulated to evaluate cohort or case series design studies. Lastly, by limiting our search to English-language publications, the potential exists that good-quality foreign studies, which might have strengthened our recommendations, were excluded.

Directions for Further Research

A priority for future research is the use of more rigorous research designs with well-dened conservative management protocols. Randomized trials with long-term follow-up are required to identify both the functional and recurrence rates. A thorough review of the biologic, physiological, and kinematic foundations for shoulder stability decits and restoration should serve as the basis for establishing an ideal exercise approach. A comprehensive program that includes appropriate immobilization (minimum three weeks) followed by intensive strengthening to restore the balance and stability of the shoulder musculature appears to be the optimal approach, although the exact parameters of this approach remain undened. Ultimately, conservative management trials should compare patient outcomes following two different conservative protocols to determine specic treatment parameters and FITT (frequency, intensity, type, and time) protocols. These studies are urgently required to provide evidence on which to base conservative management guidelines.
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The use of standardized outcome measures is a key component of these future studies. Certainly, recurrence of dislocation/subluxation is a primary outcome measure and best measured by regular prospective evaluations. However, we do not yet understand the relationship between the rate of dislocation and functional impairments. Potentially, dislocation could be a surrogate for functional impairment, although the existence of functionally impaired persons without recurrences might suggest that this relationship is not so direct. The development of scales that measure important aspects of quality of life and functional ability for instability patients is not only a vital step toward this understanding, but will also enhance the rigor of future trials. The Western Ontario Shoulder Instability (WOSI) index is an example of such a measure.24 Future prospective studies that incorporate a welldened conservative intervention and comprehensive, long-term outcome assessment are required. These studies will provide valid data that can support quantication and statistical analyses on the effectiveness of conservative management. Surgical management of instability is required for recurrent instability as well as in cases of young patients who do not improve with conservative management. Conservative management of shoulder instability plays a role in the management of shoulder instability for patients who may want to avoid surgery because of personal reasons, comorbidities, or contraindications. When a successful outcome can be obtained through conservative means, avoidance of surgery seems logical. Unfortunately, the evidence is insufcient at present as to how this successful outcome can be obtained and for which patients it should be recommended. This creates an urgent need to conduct more rigorous studies to provide evidence of conservative management effectiveness as an independent treatment or as a method to improve surgical outcomes. Lastly, it should be noted that the use of shoulder orthoses as a component of conservative management for shoulder instability has been emerging in the literature. In 1984, Methany published a case report of a custom-made orthosis used by a 16-yearold competitive downhill skier with a history of repeated dislocations to prevent extreme abduction and external rotation, thus allowing her to complete the competitive season.34 The skier also completed an exercise program for deltoid and rotator cuff strength and endurance.34 Then, in 2002, Chu investigated the effect of a shoulder brace for improving active joint reposition sense in subjects with unstable shoulders and found that a neoprene shoulder stabilizer enhanced joint position sense in those with anterior joint instability.35 Most recently, Ide et al. published the results of an exercise program performed with

a shoulder orthosis designed to xate and orient the scapula so that the humeral head can be better stabilized in the glenoid fossa for multidirectional unstable shoulders.36 Results showed a signicant decrease in instability, a decrease in pain, and an increase in strength of the rotator muscles and the scapular stabilizers (serratus anterior and rhomboids).36 Together, these promising results indicate that further research is warranted to determine the feasibility of shoulder orthoses as part of a conservative management program for shoulder instability, whereas additional investigation into the effect of joint position sense on improving joint stability may reveal an exciting new rehabilitation option.

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 activity levels. (2) EMG biofeedback is recommended as an adjunct to conservative management for returning patients to premorbid activity levels and for minimizing or alleviating symptoms. (3) Stabilization exercises alone cannot be recommended when compared with surgery for reducing the recurrence of instability, returning patients to premorbid status, or for minimizing or alleviating symptoms. (4) General undened strengthening cannot be recommended for reducing the recurrence of instability, returning patients to premorbid status, or minimizing or alleviating symptoms. (5) Conservative management consisting of immobilization for three to four weeks followed by 12 weeks of strengthening cannot be recommended over surgery for decreasing the recurrence of instability after a primary shoulder dislocation.

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