Comfort and acceptability of various immobilization positions using a shoulder external rotation and abduction brace

No Difference in Pain and Activities of Daily Living Between Immobilization in External and Internal Rotation Following Acute Anterior Shoulder Dislocation: Results of a Randomized Controlled Trial

Background The conventional treatment for anterior shoulder dislocations is immobilising the arm in adduction and internal rotation. However, recent basic science and clinical data indicate that immobilization in external rotation can reduce recurrent instability. The use of external rotation brace is not widespread, due to compliance and convenience issues. The purpose of our study is to compare pain and restriction in day-to-day activities experienced by patients after being immobilized in the two types of braces (external rotation and internal rotation) at the end of one week. Methods Between February 2023 to July 2024, 50 patients with acute shoulder dislocation (primary or recurrent) were randomized (concealed, computer-generated) to immobilization with either an internal rotation brace (n=26) or an external rotation brace (n=24). Validated scores (Pain-visual analog scale (VAS) for pain, Katz Index for independence in activities of daily living) were used to collect data on the day of Immobilization and at the end of one week of immobilization. Results There was no statistically significant difference (P>0.05) in Pain-VAS and Katz Index scores among the two brace types (external rotation and internal rotation) at the end of one week of follow-up. There was no loss in follow-up in either of our study groups. Conclusion Immobilization in external rotation after reduction of acute shoulder dislocation did not significantly differ from immobilization in internal rotation in terms of pain and limitations in activities of daily living experienced by the patient in the first week of immobilization.

A Literature Review on Whether Immobilization of the Shoulder in External Rotation Improves Healing and Prevents the Recurrence of Acute Shoulder Dislocations

Shoulder dislocations are one of the most frequent joint dislocations, with recurrent dislocations being a common complication. Common practice is to immobilize the shoulder in internal rotation for two to three weeks following closed reduction. However, recent literature suggests immobilization in external rotation can be an alternative management strategy. External rotation braces have been manufactured over the years to support and maintain this position. This literature review aims to gather current evidence on the conservative management of primary traumatic anterior shoulder dislocations and compare the immobilization of the shoulder joint in internal and external rotation. A literature search and review was performed using PubMed and Google Scholar. Key phrases and words that were used in the search engines included "shoulder immobilization" AND "external rotation", "anterior shoulder dislocation immobilization" AND "external rotation", "reduced recurrence rate of shoulder dislocation" AND "external rotation", "external rotation immobilization" AND "Bankart lesion" and "internal versus external rotation" AND "shoulder dislocation". The reviewed articles included were dated from 2014 to 2024 but additional valuable studies dating earlier than 2014 were also included to provide a foundation of understanding to this review. Included were nine clinical studies and randomized controlled trials, three cadaveric studies, eight studies focusing on magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA) or arthroscopy, and seven systematic reviews and meta-analyses. Research revealed improved coaptation of the labrum on the glenoid rim in external rotation not only in cadavers but also in patients with the aid of various imaging techniques. However, these findings were not consistently observed when translated into clinical trials. Based on the available data presented in this literature review, there remains a deficiency in evidence to exclusively support the use of external rotation immobilization over conventional internal rotation immobilization after primary traumatic anterior shoulder dislocations. External rotation immobilization may benefit a specific population, particularly those that fall in the 20-40-year-old age group, with a specific injury pattern, such as Bankart lesions and greater tuberosity fractures; therefore, further studies are required to determine who will benefit the most from such interventions.

Sling Results in Better Sleep Quality and Less Anxiety Early After Arthroscopic Rotator Cuff Repair: A Randomized Single-Blinded Trial

BACKGROUND

Sleep disturbance is commonly reported by patients wearing an abduction brace after arthroscopic rotator cuff repair (ARCR). Although a sling has been proven noninferior to an abduction brace for function and repair integrity, there is no evidence-based medical support for the advantage of the sling in improving sleep quality compared with a brace.

PURPOSE/HYPOTHESIS

This study aimed to compare the effects of a sling and an abduction brace on sleep quality and clinical outcomes after ARCR. It was hypothesized that immobilization in a sling would result in better sleep quality while not deteriorating clinical outcomes and bone-tendon healing compared with an abduction brace.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 142 consecutive patients with rotator cuff tears were randomly assigned to 2 groups: (1) the brace group, receiving abduction brace immobilization for 6 weeks, and (2) the sling group, receiving sling immobilization after ARCR for 6 weeks. The primary outcome was the Pittsburgh Sleep Quality Index at 6 weeks postoperatively. Secondary outcomes-American Shoulder and Elbow Surgeons score, Self-rating Anxiety Scale, pain, satisfaction, and tendon healing (using ultrasonography)-were evaluated until 1 year postoperatively.

RESULTS

Complete outcome measurements were obtained for 131 patients. The Pittsburgh Sleep Quality Index at 6 weeks was 11.1 ± 2.7 for the brace group and 9.2 ± 2.3 for the sling group (P < .001), indicating a statistically significant advantage for the sling group. The sling group also reported significantly lower Self-rating Anxiety Scale, lower pain level, and higher satisfaction scores at 6 weeks. No significant difference was observed in outcome measures between groups at 1 year. The tendon healing rates (91% vs 88%, respectively) were comparable between the brace and sling groups within the first 1 year (risk ratio, 1.03 [95% CI, 0.92-1.16]; P = .59).

CONCLUSION

The use of a sling resulted in better sleep quality, less anxiety, and higher satisfaction compared with an abduction brace in the first 6 weeks after ARCR; nevertheless, functional outcomes and repair integrity were similar at 1 year postoperatively between the 2 groups. These findings indicate that a sling is appropriate for the postoperative care of ARCR. However, caution should be used when interpreting these results because the clinical relevance of sling-related benefits warrants further investigation.

REGISTRATION

ChiCTR2200059967 (Chinese Clinical Trial Registry).

An Expedited Sling Immobilization Protocol After Isolated Biceps Tenodesis Results in Clinical and Patient-Reported Postoperative Outcomes Equivalent to a Standard Rehabilitation Protocol

Purpose

To characterize clinical and patient-reported outcomes for patients after isolated biceps tenodesis (BT) who underwent either standard or expedited sling immobilization protocols following surgery.

Methods

This retrospective cohort study compared patients who were assigned to use a sling for either 4 to 6 weeks (standard) or 0 to 2 weeks (expedited) following an isolated BT. Primary endpoint included rate of re-rupture, surgical revision, loss of fixation, and Popeye deformity. Secondary endpoints included shoulder range of motion (ROM) as well as pre- and postoperative patient-reported outcomes (PROs) of pain and function. Missing data were managed via multiple imputation with chained equations. Complication prevalence 95% confidence intervals were calculated using the Clopper Pearson method and a series of hierarchical mixed effects linear regressions were performed to assess differences between sling interventions in PROs and ROM.

Results

The average age of the standard cohort (n = 66) was 49 years (±14 years), and the average age of the expedited cohort (n = 69) was 47 years (±14 years). The expedited and standardized cohorts demonstrated 0.4 and 0.3 complications per 10,000 exposure days, respectively, with no significant difference between groups (1.4 [95% confidence interval 0.2-10.0], P = .727). There was no demonstrated difference in forward flexion, abduction, or external ROM. The expedited group had less improvement in visual analog scale for pain scores that was not clinically significant and there were no differences in PROs of function.

Conclusions

No statistically significant difference in the rate of re-rupture, surgical revision, loss of fixation, or Popeye deformity was noted between protocols after isolated BT. Furthermore, there were no clinically significant differences in ROM or PROs identified between protocols after isolated BT. This study suggests that patients who have undergone isolated BT may safely discontinue sling use within 2 weeks after surgery.

Level of Evidence

Level III, retrospective comparative study.

Shoulder brace has no detrimental effect on basic spatio-temporal gait parameters and functional mobility after arthroscopic rotator cuff repair

BACKGROUND

The risk of falls in patients undergoing orthopedic procedures is significant in terms of health and socioeconomic effects.

RESEARCH QUESTION

Is there an influence of the shoulder abduction brace (SAB) on gait parameters in patients undergoing arthroscopic rotator cuff repair (ARCR)?

METHODS

Thirty-five patients undergoing ARCR, who used a 15° SAB in the postoperative period, were included in a prospective study. Participants underwent gait analysis preoperatively (T0), 24 h after surgery (T1), 1 week (T2), and 4 weeks after surgery (1 week after SAB removal) (T3) by using a wearable inertial sensor (BTS G-Walk sensor). Gait Parameters (cadence, speed, right (R) and left (L) step length, gait and propulsion-R and L symmetry indices) and functional mobility (agility and balance) were assessed using the 10-meter test (10MWT) and the Timed Up and Go (TUG) test, respectively.

RESULTS

There were 22 men and 13 women with a median age of 56 (IQR 48.0-61.0) years. The right upper limb was involved in 83% of cases. Regarding the 10MWT, speed was significantly higher at T0 than at T1 (p < 0.01) and significantly lower at T1 than at T3 (p < 0.05). Cadence was significantly lower at T1 than at T3 (p < 0.05). Propulsion-R was significantly higher at T3 than at T1 (p < 0.01), whereas propulsion-L was significantly lower at T1 than at T0 (p < 0.05) and significantly higher at T2 and T3 than T1 (p < 0.01 for all). No significant differences were found for R and L step lengths as well as for symmetry index (p > 0.05). Regarding TUG test, the final turning phase was significantly higher at T2 than at T3 (p < 0.01).

SIGNIFICANCE

The results demonstrated that the use of the SAB affected gait speed and propulsion only 24 h after ARCR, but no effects were reported at long-term observations.

Positioning efficacy and comfort profile of shoulder support braces: A randomized repeated-measures study using three-dimensional kinematic analysis

BACKGROUND

Shoulder bracing is very common in musculoskeletal rehabilitation.

OBJECTIVE

In this study, the positioning efficacy of shoulder support braces was investigated by analyzing their three-dimensional kinematic properties, as well as their perceived comfort was investigated with user ratings.

STUDY DESIGN

A randomized repeated-measures study.

METHODS

Seventeen asymptomatic participants were included. Scapular, humeral, and thoracic kinematics for all participants were measured using an electromagnetic tracking device in 6 experiments in randomized order: no brace, neutral brace, abduction brace, internal rotation brace, 15-degree external rotation brace (ER15-B), and 30-degree external rotation brace (ER30-B). Also, comfort ratings were obtained during each session.

RESULTS

Internal rotation brace achieved a mean of 29.34° of humerothoracic internal rotation while providing increased scapular internal rotation and upward rotation ( p < 0.05). Abduction brace achieved a mean of 45.39° of humerothoracic and 39.58° of glenohumeral elevation coupled with increased scapular upward rotation, posterior tilt, and humeral internal rotation ( p < 0.05). 30-Degree external rotation brace achieved a mean of 33.25° of glenohumeral external rotation and resulted in increased scapular external rotation, upward rotation, posterior tilt, and humeral external rotation ( p < 0.05). Abduction brace, internal rotation brace, ER15-B, and ER30-B moved the thoracic spine into a more axial rotation in the contralateral direction. Internal rotation brace, ER15-B, and ER30-B were rated more uncomfortable when compared with the no brace condition, with no significant differences observed among the braces.

CONCLUSIONS

The positioning efficacy was enhanced when an abduction pillow and external rotation wedge were applied. Selection of commercially available shoulder support braces should involve consideration of whether it can achieve the desired position and orientation as well as its comfort profile.

Immobilization in External Rotation Reduces the Risk of Recurrence After Primary Anterior Shoulder Dislocation: A Meta-analysis

Background

The best method for nonsurgical treatment after primary dislocation of the shoulder is not clear. The efficacy of immobilization with the arm in external rotation (ER) compared with internal rotation (IR) remains controversial.

Purpose

To determine the efficacy of ER immobilization versus IR immobilization on recurrence rate after primary dislocation of the shoulder from the evidence of randomized controlled trials.

Study Design

Systematic review; Level of evidence, 2.

Methods

Electronic databases (MEDLINE [Ovid SP], PubMed, Web of Science, EBM reviews, and CINAHL) and available proceedings according to the abstracts of major international meetings related to or including shoulder injuries and trauma were used to search for randomized controlled trials. Two independent investigators determined eligibility and carried out data extraction from the selected studies.

Results

A total of 9 studies (817 patients) were selected for this meta-analysis. They included 668 male and 149 female patients, with a mean age ranging from 20.3 to 37.5 years. In the 9 pooled studies, the recurrence rate of shoulder dislocation was 21.5% (84/390) in the ER group versus 34.9% (130/373) in the IR group. ER immobilization significantly reduced the recurrence rate compared with IR immobilization (risk ratio, 0.56; P = .007). In the subgroup analysis of those immobilized full-time, ER immobilization was significantly more effective than IR immobilization in reducing the recurrence rate (risk ratio, 0.57; P = .01). In the subgroup analysis of age, ER immobilization was significantly more effective than IR immobilization in those aged 20 to 40 years but not in those younger than 20 years.

Conclusion

This meta-analysis demonstrates that ER immobilization reduces the recurrence rate after primary shoulder dislocation compared with IR immobilization in patients older than 20 years. When treating a patient with primary shoulder dislocation, the clinician should provide this information to the patient before a treatment method is selected.

How shoulder immobilization influences daily physical activity - an accelerometer based preliminary study

Background

To investigate the influence of shoulder immobilization on daily physical activity.

Introduction

The harmful effect of sedentary behavior does not receive much attention in orthopedic surgery even though immobilization, especially of the lower extremity, has been associated with reduced physical activity. Immobilization of the shoulder is common after reconstructive shoulder surgery and could also potentially lead to reduced physical activity and have a negative effect on a patient’s general health.

Method

Twenty-one healthy volunteers were immobilized in an orthosis (DJO Ultrasling III) for 10 h on two consecutive days. In the following week, activity was measured on the same days without the orthosis. Activity including gait cycles per minute and total gait cycles per day was measured by accelerometer based step count StepWatchTMActivity Monitor. Average age was 26 +/− 3 years. A questionnaire was administered to evaluate subjective activity.

Results

Participants wearing the shoulder orthosis were significantly less active than without immobilization by 2227.5 gait cycles/day (5501.2 with SO, 7728.7 without SO). Also, significantly more time in sedentary behavior occurred (< 400 steps/h) when the shoulder was immobilized. Patients were significantly more active without shoulder orthosis in medium level activities (800–999 steps/h). Differences for low (400–799 steps/h) and high activity levels (> 1000 steps/h) were not statistically significant. Subjective limitations while wearing the orthosis were graded at 2.343 on a scale of 0–4.

Conclusion

Results of this study show that even in young, healthy volunteers immobilization of the shoulder in an orthosis for 2 days leads to significantly reduced activity levels. A negative influence on general health, especially in older patients who are immobilized for up to 6 weeks, can potentially occur. Promoting physical activity during the immobilization period should be part of rehabilitation after injuries/surgery of the shoulder.

Trial registration

Retrospectively registered in DRKS (DRKS00017636).

Position of Immobilization After First-Time Traumatic Anterior Glenohumeral Dislocation: A Literature Review

Anterior glenohumeral dislocation affects about 2% of the general population during the lifetime. The incidence of traumatic glenohumeral dislocation ranges from 8.2 to 26.69 per 100 000 population per year. The most common complication is recurrent dislocation occurring in 17–96% of the patients. The majority of patients are treated conservatively by closed reduction and immobilization in internal rotation for 2–3 weeks. However, no clear conservative treatment protocol exists. Immobilization in external rotation can be considered an alternative. A range of external rotation braces are commercially available.

The purpose of this work was to review the current literature on conservative management of glenohumeral dislocation and to compare the results of immobilization in internal and external rotation.

A comprehensive literature search and review was performed using the keywords “glenohumeral dislocation”, “shoulder dislocation”, “immobilization”, “external rotation”, and “recurrent dislocation” in PubMed, MEDLINE, Cochrane Library, Scopus, and Google Scholar databases from their inceptions to May 2016.

Three cadaveric studies, 6 imaging studies, 10 clinical studies, and 4 meta-analyses were identified. The total number of 734 patients were included in the clinical studies.

Literature analysis revealed better coaptation of the labrum on the glenoid rim in external rotation in cadaveric and imaging studies. However, this tendency was not confirmed by lower redislocation rates or better quality of life in clinical studies.

On the basis of the available literature, we cannot confirm the superiority of immobilization in external rotation after glenohumeral dislocation when compared to internal rotation. A yet-to-be-determined group of patients with specific labroligamentous injury pattern may benefit from immobilization in external rotation. Further studies are needed to identify these patients.