Developing a Rehabilitation Guideline (REGUIDE) for Patients Undergoing an Arthroscopic Bankart Repair After Traumatic Anterior Shoulder Dislocation, Focusing on Managing Apprehension: An International Delphi-Based Consensus Study.

OBJECTIVE: We aimed to develop a consensus-based rehabilitation guideline specifically designed to reduce apprehension following arthroscopic Bankart repair after traumatic anterior shoulder dislocation. DESIGN: Delphi-based consensus. METHOD: A comprehensive list of interventions for potential inclusion in a postoperative rehabilitation guideline was developed. American and European physiotherapists and orthopedic surgeons were invited to participate in a Delphi panel, engaging in 3 survey rounds. The health professionals were surveyed about their level of agreement on both initially listed and newly suggested interventions. Consensus was established when a "critical-to-include" rating was given in ≥70% of all responses. Ten former patients were consulted to identify the intervention during standard care rehabilitation that had the most impact on reducing postoperative apprehension following ABR. Any interventions not initially listed in the first round were added to the second survey round of the Delphi process. RESULTS: Forty-four health professionals reached consensus on a set of 27 interventions for managing apprehension after arthroscopic Bankart repair. New interventions included gradual exposure to shoulder positions eliciting apprehension, training in anterior stability-provoking positions, and education addressing the impact of psychosocial factors. Former patients identified specific interventions that were effective in reducing postoperative apprehension following ABR. These interventions encompassed medicine ball throws, active-assisted wall slides, and kinetic chain exercises in anterior stability-provoking positions. CONCLUSION: Our Delphi process informed expert recommendations for various interventions aimed at addressing apprehension associated with ABR. The recommendations were the foundation for developing a rehabilitation guideline (REGUIDE). The REGUIDE integrates principles from cognitive-behavioral therapy to improve rehabilitation and mitigate apprehension. J Orthop Sports Phys Ther 2024;54(5):1-13. Epub 20 March 2024. doi:10.2519/jospt.2024.12106.

A modified Delphi study to identify which items should be evaluated in shoulder instability research: a first step in developing a core outcome set.

Background: The aim of this study was to identify items that healthcare providers and/or patients consider important to include in a questionnaire for clinical trials and cohort studies in shoulder instability research. This could serve as a basis to develop a core outcome set for shoulder instability research. Methods: Healthcare providers and patients were included in a panel for a modified Delphi consensus study. The study consisted of three rounds, comprising (1) identifying items, (2) rating the importance of the items, and (3) rating the importance again after seeing a summary of the results of round two. Importance was rated on a 9-point Likert scale. Consensus was defined as ≥ 80% of the panel giving a score of 7 or higher. Results: In total, 44 healthcare providers and 30 patients completed all three rounds. Round one identified 54 items. After round three, the panel reached a consensus on 11 items that should be included in a questionnaire, comprising re-dislocation (99%), instable feeling of the shoulder (96%), limitations during sport (93%), patient satisfaction with the shoulder (93%), fear/anxiety for re-dislocation (91%), range of motion (88%), return to old level of functioning (85%), performing daily activities (85%), return to sport (82%), return to work (82%), and trusting the shoulder (81%). Conclusion: Healthcare providers and patients reached a consensus on 11 items that should be included in a questionnaire for shoulder instability research. These items can facilitate design and development of future clinical trials and form the basis for the development of a core outcome set.

The Modified Tampa-Scale of Kinesiophobia for Anterior Shoulder Instability.

Purpose: To assess content validity and to modify the Tampa Scale of Kinesiophobia (TSK) to make it suitable for application in patients with anterior shoulder instability. Methods: A four-round Delphi method was performed to establish expert consensus on developing the Tampa Scale of Kinesiophobia for patients with anterior shoulder instability (TSK-SI) using an expert group of Dutch shoulder-specialized orthopedic surgeons and physiotherapists. During round 1, experts were asked to score the 17 items of the original TSK on relevance and construction using the COSMIN guidelines. With this feedback, questions were reviewed and modified. During round 2, experts were asked to score the modified items. This process was repeated until consensus was established. Then, patients were asked to participate in a moderator-guided, three-step-test interview using a Web-based platform to assess the modified scale. Sessions were recorded and evaluated by the working group. The modified scale was finally adjusted on the basis of the input of these patients. Results: Thirty Dutch shoulder experts were included, of which 25 completed all 4 rounds, after which consensus was established. One question was added to the modified scale based on feedback in round 1, establishing the 18-item TSK-SI. Sixteen patients with shoulder instability were included, which all completed the three-step test interview. Following this, question 4 (changed to present tense) and question 7 (hypothetical component added) were adjusted, resulting in the final TSK-SI. Conclusions: This consensus modification of the TSK to TSK-SI can support the content validity of the instrument to assess kinesiophobia in patients with anterior shoulder instability. These modifications may improve the responsiveness and validity of the TSK-SI, as it does not match all the items of the original TSK. Level of evidence: Level V, consensus statement.

Surgical Intervention Following a First Traumatic Anterior Shoulder Dislocation Is Worthy of Consideration.

Up to 60% of patients experience recurrence after a first traumatic anterior shoulder dislocation (FTASD), which is often defined as having experienced either dislocation or subluxation. Thus surgical intervention after FTASD is worthy of consideration and is guided by the number of patients who need to receive surgical intervention to prevent 1 redislocation (i.e., number needed to treat), (subjective) health benefit, complication risk, and costs. Operative intervention through arthroscopic stabilization can be successful in reducing recurrence risk in FTASD, as has been shown in multiple randomized controlled trials. Nevertheless, there is a large "gray area" for the indication of arthroscopic stabilization, and it is therefore heavily debated which patients should receive operative treatment. Previous trials showed widely varying redislocation rates in both the intervention and control group, meta-analysis shows 2% to 19% after operative and 20% to 75% after nonoperative treatment, and redislocation rates may not correlate with patient-reported outcomes. The literature is quite heterogeneous, and a major confounder is time to follow-up. Furthermore, there is insufficient standardization of reporting of outcomes and no consensus on definition of risk factors. As a result, surgery is a reasonable intervention for FTASD patients, but in which patients it best prevents redislocation requires additional refinement.

An overview of effective and potential new conservative interventions in patients with frozen shoulder.

Frozen shoulder (FS) is a pathology that is difficult to understand and difficult to manage. Over the last ten years, contradictory and new evidence is provided regarding the recovery and its natural course. This narrative review provides new information about the diagnosis and conservative treatment of patients with FS and ongoing research hypotheses that might provide new insights in the pathology and treatment options. FS has a characteristic course. People with Diabetes Mellitus and thyroid disorders have a higher risk of developing a FS. The diagnosis FS is based on pattern recognition and physical examination. Additionally, 'rule-in' and 'rule-out' criteria can be used to increase the likelihood of the frozen shoulder diagnosis. Recommended and most common physical therapy interventions are mobilization techniques and exercises, in which tissue irritability can guide its intensity. In addition, physical therapy is often complementary with patient education and pharmacotherapy. The latest evidence-based practice related to FS is proprioceptive neuromuscular facilitation and mirror therapy. In addition, interventions like pain neuroscience education, high-intensity interval training and lifestyle changes are still hypothetical. Finally, better insight in the involvement of biochemical processes, function of myofibroblasts and matrix metalloproteinases can provide better understanding in the pathophysiology and will be addressed in current review.

Interrater agreement and reliability of clinical tests for assessment of patients with shoulder pain in primary care.

Background: There is limited information about the agreement and reliability of clinical shoulder tests. Objectives: To assess the interrater agreement and reliability of clinical shoulder tests in patients with shoulder pain treated in primary care. Methods: Patients with a primary report of shoulder pain underwent a set of 21 clinical shoulder tests twice on the same day, by pairs of independent physical therapists. The outcome parameters were observed and specific interrater agreement for positive and negative scores, and interrater reliability (Cohen's kappa (κ)). Positive and negative interrater agreement values of ≥0.75 were regarded as sufficient for clinical use. For Cohen's κ, the following classification was used: <0.20 poor, 0.21-0.40 fair, 0.41-0.60 moderate, 0.61-0.80 good, 0.81-1.00 very good reliability. Participating clinics were randomized in two groups; with or without a brief practical session on how to conduct the tests. Results: A total of 113 patients were assessed in 12 physical therapy practices by 36 physical therapists. Positive and negative interrater agreement values were both sufficient for 1 test (the Full Can Test), neither sufficient for 5 tests, and only sufficient for either positive or negative agreement for 15 tests. Interrater reliability was fair for 11 tests, moderate for 9 tests, and good for 1 test (the Full Can Test). An additional brief practical session did not result in better agreement or reliability. Conclusion: Clinicians should be aware that interrater agreement and reliability for most shoulder tests is questionable and their value in clinical practice limited.

Measurement of scapular dyskinesis using wireless inertial and magnetic sensors: Importance of scapula calibration.

Measurement of 3D scapular kinematics is meaningful in patients with shoulder pathologies showing scapular dyskinesis. This study evaluates the effect of single and double anatomical calibration (0° and 120°) with a scapula locator compared to standard calibration (using sensor alignment with the spina scapulae and static upright posture, ISEO-protocol) on 3D scapular kinematics measured with an inertial and magnetic measurement system (IMMS). Ten patients with scapular dyskinesis performed humeral anteflexion and abduction movements while 3D scapular kinematics were measured using IMMS sensors. The sensor on the scapula was anatomically calibrated (i) according to the ISEO-protocol, (ii) using single scapula locator calibration (0°) and (iii) double scapula locator calibration (0° and 120°). For calibration, the scapula locator (with IMMS) was positioned on the scapula, while holding the humerus at several anteflexion and abduction postures. Single and double calibration resulted in a significant increase of scapular anterior tilt (14-30°) with respect to the skin-fixed sensor (ISEO). Protraction angles were not significantly different. During anteflexion, double calibration did not show a significant increase in lateral rotation compared to single calibration. During abduction of >90°, double calibration showed 10-14° increased lateral rotation with respect to single calibration, although this was not significant (P>0.06). Calibration with a scapula locator when applying IMMS is necessary, because measures of scapular anterior tilt are grossly underestimated with the ISEO-protocol. For shoulder movements that exceed 90° elevation, a double calibration prevents small but relevant underestimation of lateral rotation angles of the scapula.

Reliability and precision of 3D wireless measurement of scapular kinematics.

To direct interventions aimed at improving scapular position and motion in shoulder pathologies, a clinically feasible, objective, sensitive and reliable assessment of scapular dyskinesis is needed. The aim of this study is to evaluate the intra- and inter-observer reliability and the precision of 3D scapula kinematics measurement using wireless sensors of an inertial and magnetic measurement system (IMMS). Scapular kinematics during humerus anteflexion and abduction of 20 subjects without shoulder pathologies were measured twice by two observers at two different days, using IMMS. Similar movement patterns and corresponding high intraclass correlation coefficients were found within (intra) and between (inter) observers, especially for scapular retraction/protraction (0.65-0.85) and medio/lateral rotation (0.56-0.91). Lowest reliability and highest difference in range of motion were observed for anterior/posterior tilt. Medio/lateral rotation and anterior/posterior tilt showed a high precision, with standard error of measurement being mostly below 5°. The inter-observer measurements of retraction/protraction showed lowest precision, reflected in systematic differences. This is caused by an offset in anatomical calibration of the sensors. IMMS enables easy and objective measurement of 3D scapula kinematics. Further research in a patient population should focus on clinical feasibility and validity for measurement of scapular dyskinesis. This would include the application of a scapula locator to enhance anatomical calibration.

Measurement properties of the Dutch version of the Western Ontario Shoulder Instability Index (WOSI).

BACKGROUND: The Western Ontario Shoulder Instability Index (WOSI) is a disease-specific shoulder questionnaire to measure quality of life in patients with shoulder instability. The aim of the present study was to translate the WOSI into Dutch and assess its principal measurement properties. METHODS: The WOSI was translated into Dutch according to guidelines in the literature. Fifty-two shoulder instability patients completed the questionnaire twice within 2 weeks. We assessed internal consistency (Cronbach's alpha), test-retest reliability [Intraclass Correlation Coefficient (ICC)], standard error of measurement (SEM), smallest detectable change (SDC) and reliable change index. The Bland-Altman analysis was applied to assess test-retest agreement and floor and ceiling effects were calculated. RESULTS: Cronbach's alpha was 0.95 for the total WOSI score (range 0.88-0.95 for the 4 domains). ICC for the total WOSI score was 0.91 (range 0.79-0.90 for domains), SEM was 130.6 for the total WOSI score resulting in a SDC of 362.0, which is 17.3 % of the maximum obtainable score of 2100. Bland-Altman analysis showed no systematic differences or consistent bias between the two assessments. We observed no relevant floor and ceiling effects. CONCLUSION: The results of the present study suggest the Dutch version of the WOSI is a reliable tool for clinical assessment and scientific evaluation. It shows high values for Cronbach's alpha and ICC implying excellent internal consistency and good test-retest reliability.

Reproducibility of the Dutch version of the Western Ontario rotator cuff Index.

BACKGROUND: The Western Ontario Rotator Cuff Index (WORC) is a disease-specific shoulder questionnaire, originally developed at the University of Western Ontario, to measure quality of life in patients with rotator cuff disease (RCD). The aim of the present study was to cross-culturally adapt the WORC for use in the Netherlands and to evaluate the reproducibility in patients with RCD. MATERIALS AND METHODS: The WORC was translated into Dutch according to leading guidelines in the literature, and 52 patients with RCD completed the questionnaire twice within 2 weeks. The Cronbachs α and the intraclass correlation coefficient (ICC) were calculated, Bland-Altman analysis was applied, and the smallest detectable change (SDC) and reliable change index (RCI) were determined. RESULTS: The Cronbachs α ranged from 0.91 to 0.97 for the total WORC score and for the 5 domains. High ICCs were found for the WORC total score (0.94) and for the separate domains (range, 0.85-0.91). Bland-Altman analyses showed no systematic differences between assessments. SDC was 355.7 for the total WORC score, varying from 80.4 to 148.0 for the domains, resulting in RCIs of 16.9% for the total WORC score and 24.7% to 30.2% for the domains. CONCLUSIONS: The results of the present study suggest good reproducibility of the Dutch version of the WORC in Dutch-speaking patients with RCD. Additional research on the validation of the Dutch version of the WORC is required in the near future.