A systematic review and meta-analysis of operative versus non-operative management for first time traumatic anterior shoulder dislocation in young adults

Negative expectations and related nocebo effects in shoulder pain: a perspective for clinicians and researchers

The nocebo effect, a phenomenon wherein negative expectations can worsen symptoms, is increasingly acknowledged within the context of musculoskeletal conditions. While experimental evidence has, to some extent, examined negative expectations in shoulder pain, their specific relationship with nocebo effects and their manifestation in clinical practice remains unexplored. In this perspective, clinicians and researchers are guided by first examining the psychobiology and neurophysiology underlying nocebo effects from a basic science standpoint, thereby equipping clinicians with a robust understanding of the phenomenon. What are considered the primary potential sources of nocebo effects in individuals with shoulder pain are then outlined - namely, diagnostic labels, diagnostic imaging and special tests, the medicalization of normality, and overtreatment. Practical clinical strategies are subsequently proposed to mitigate nocebo effects arising from these sources. Finally, the research implications for advancing the study of nocebo effects in people with shoulder pain are discussed. Overall, this perspective provides a comprehensive overview of the impact of negative expectations and associated nocebo effects on shoulder pain outcomes. By identifying potential sources of nocebo effects that may emerge in everyday clinical practice, guidance on mitigating related negative expectations in patients with shoulder pain is offered.

An umbrella review of systematic reviews and meta-analyses for assessment and treatment of acute shoulder dislocation

OBJECTIVE

This study aims to provide a comprehensive review of the current evidence on accurate and rapid diagnostic methods, effective and safe shoulder dislocation reduction techniques, pharmacological treatment, and post-reduction care for acute anterior shoulder dislocation in the emergency department (ED).

METHODS

We conducted a systematic review of the literature up to December 31, 2022, with an additional search conducted up to August 31, 2024. Databases searched included Cochrane Database of Systematic Reviews, MEDLINE, Embase, CINAHL, DARE, PROSPERO, OpenGrey, and Google Scholar. We reviewed systematic reviews and meta-analyses on assessment and intervention for acute anterior shoulder dislocation. Data extraction and quality assessment were performed independently by two reviewers. The quality of evidence was evaluated using the Cochrane Risk of Bias tool and the GRADE approach, while the methodology was assessed using AMSTAR 2.

RESULTS

From an initial 1345 records, 30 studies met the inclusion criteria. These included 4 articles on point-of-care ultrasound (POCUS), 5 on analgesia and anesthesia, 3 on closed reduction techniques, 10 on surgical Bankart repair, 9 comparing external and internal rotation immobilization, and 1 on nerve injuries, including duplicates. POCUS demonstrated high diagnostic accuracy comparable to radiography for shoulder dislocations and associated fractures. Analgesia and anesthesia studies showed that intra-articular anesthesia (IAA) is as effective as intravenous sedation (IVS) with fewer adverse events and shorter ED stays. Three meta-analyses on closed reduction techniques revealed no significant differences in success rates among various methods, but the FARES method was noted for superior pain management. Ten reviews on surgical Bankart repair consistently showed reduced redislocation rates, especially in younger patients, compared to non-surgical treatments including internal and external rotation immobilization. Four recent reviews reported external rotation immobilization was more effective than internal rotation in preventing redislocations. Nerve injuries were common, with the axillary nerve most frequently affected.

CONCLUSIONS

Emergency physicians managing anterior shoulder dislocation should employ POCUS for diagnosis, prioritize intra-articular anesthesia, master various reduction techniques including the FARES method, refer patients to an orthopedic surgeon for follow-up and potential surgery to prevent redislocation, and be vigilant about nerve damage.