Heavy shoulder strengthening exercise in people with hypermobility spectrum disorder (HSD) and long-lasting shoulder symptoms: a feasibility study

Effects of compression garments on balance in hypermobile Ehlers-Danlos syndrome: a randomized controlled trial

PURPOSE

To evaluate the immediate and 4-week effects of compression garments (CG) on balance using a force platform during 8 different visual, static, and dynamic conditions in hypermobile Ehlers-Danlos Syndrome (hEDS) patients.

METHODS

Thirty-six participants were randomly assigned to a group: physiotherapy alone (PT, n = 19) or physiotherapy and daily CG wearing for 4 weeks (PT + CG, n = 17). Both attended 12 physiotherapy sessions (strengthening, proprioception, and balance exercises) for 4 weeks. Primary outcome: sway velocity of the centre of pressure (COP) measured before, immediately with the CG, and at 4 weeks. Secondary outcomes: ellipse area, Romberg quotient, and pain.

RESULTS

Sway velocity in dynamic conditions decreased immediately with the CG. After 4 weeks of intervention, sway velocity (95% CI 4.36-39.23, effect size 0.93) and area (95% CI 146-3274, effect size 0.45) on the laterally oscillating platform with eyes-closed improved more in the PT + CG group than the PT group. Romberg quotient on foam cushion improved more in the PT + CG than the PT group. Pain decreased in both groups after 4 weeks with no between-group difference.

CONCLUSION

CG combined with physiotherapy improved dynamic balance measured with COP variables significantly more than physiotherapy alone in people with hEDS.

TRIAL REGISTRATION

NCT03359135.

One-year effectiveness of high-load compared with low-load strengthening exercise on self-reported function in patients with hypermobile shoulders: a secondary analysis from a randomised controlled trial

OBJECTIVES

To investigate the long-term effectiveness of high-load versus low-load strengthening exercise on self-reported function in patients with hypermobility spectrum disorder (HSD) and shoulder symptoms.

METHODS

A secondary analysis of a superiority, parallel-group, randomised trial (balanced block randomisation 1:1, electronic concealment) including adult patients (n=100) from primary care with HSD and shoulder pain and/or instability ≥3 months. Patients received 16 weeks of shoulder exercises (three sessions/week): HEAVY (n=50, full-range, high-load, supervised twice/week) or LIGHT (n=50, neutral/mid-range, low-load, supervised three times in total). The 1-year between-group difference in change in self-reported function was measured using the Western Ontario Shoulder Instability Index (WOSI, scale 0-2100, 0=best). Secondary outcomes were self-reported measures including changes in shoulder-related symptoms, function, emotions and lifestyle, quality of life, patient-perceived effect, treatment utility and adverse events. A blinded analyst conducted the analyses using linear mixed model repeated measurements analysis.

RESULTS

One-year data were available in 86 out of 100 participants (79% women, mean age 37.8 years) (LIGHT 84%, HEAVY 88%). The mean WOSI score between-group difference favoured HEAVY (-92.9, 95% CI -257.4 to 71.5, p=0.268) but was not statistically significant. The secondary outcomes were mostly inconclusive, but patients in HEAVY had larger improvement in the WOSI emotions subdomain (-36.3; 95% CI -65.4 to -7.3, p=0.014). Patient-perceived effect favoured HEAVY anchored in WOSI-emotions (55% vs 31%, p=0.027) and WOSI-lifestyle (50% vs 29%, p=0.042).

CONCLUSION

High-load shoulder strengthening exercise was not superior to low-load strengthening exercise in improving self-reported function at 1 year. High-load strengthening exercise may be more effective in improving patient emotions about shoulder pain and function, but more robust data are needed to support these findings.

TRIAL REGISTRATION NUMBER

NCT03869307.

Krafttraining bei Frauen mit generalisierter Hypermobilität: Machbarkeit, Beschwerden und Effekte

Hintergrund Eine generalisierte Hypermobilität liegt vor, wenn die Beweglichkeit in mehreren Gelenken das übliche Maß übersteigt. Bis zu 30 % der Frauen und 10 % der Männer sind davon betroffen. Hypermobilität ist keine Pathologie, wenn sie jedoch mit Schmerzen und weiteren Symptomen einhergeht, kann sie die Gesundheit und Alltagsfunktionen beeinträchtigen. Zur physiotherapeutischen Behandlung gibt es wenige Studien, wobei Krafttraining eine mögliche Intervention sein könnte.

Ziel Erfassung der Machbarkeit und des Effekts eines Krafttrainings für Frauen mit generalisierter Hypermobilität.

Methode Pre-post-Studie, in der hypermobile Frauen (Beighton-Score > 5) zwischen 20 und 40 Jahren während 12 Wochen ein Krafttraining an Geräten, fokussiert auf Beine und Rücken, absolvierten. Mithilfe eines Protokolls und wöchentlicher Fragebogen wurden das Training und dadurch ausgelöste Beschwerden analysiert. Vor und nach dem Training wurde die Kraft der Knieflexoren und -extensoren sowie der Muskelquerschnitt am Oberschenkel gemessen. Die Analyse erfolgte primär deskriptiv, zusätzlich erfolgte ein Vergleich von 2 Subgruppen mittels Mann-Whitney-U und Chi2-Test.

Ergebnisse 46 Teilnehmerinnen (26,3 ± 4,3 Jahre) absolvierten das Training. 6 davon brachen die Studie vorzeitig ab, davon eine wegen Rückenschmerzen aufgrund einer Diskushernie. 72,5 % der verbleibenden 40 Teilnehmerinnen absolvierten 20 oder mehr Trainings. In 34 % der Trainingswochen wurden geringe Beschwerden angegeben, mehrheitlich an Knie und Rücken. Der Einsatz der verwendeten Gewichte war oft tief, so wurde auf der Legpress mit durchschnittlich 44,8 % des Körpergewichts begonnen, nach 12 Wochen lag das Trainingsgewicht im Mittel bei 52,2 kg, was 85,7 % des Körpergewichts entspricht. Bei der Kraft und beim Muskelquerschnitt wurden keine signifikanten Verbesserungen erreicht, wobei bis zu 17 Teilnehmerinnen (42,5 %) eine Verbesserung von mehr als 10 % erreichten.

Schlussfolgerung Das Krafttraining war für die meisten Teilnehmerinnen machbar und gut verträglich. Das mehrheitlich selbstgesteuerte Training war zu wenig intensiv, um eindeutige Auswirkungen auf Kraft oder Muskelmasse zu erreichen, obwohl einzelne Teilnehmerinnen durchaus davon profitierten. In weiteren Studien sollten individuellere und enger begleitete Trainingsprogramme untersucht werden.

Management of Shoulder Instability in Patients with Underlying Hyperlaxity

PURPOSE OF REVIEW

Shoulder instability in patients with underlying joint hyperlaxity can be challenging to treat. Poorly defined terminology, heterogeneous treatments, and sparse reports on clinical outcomes impair the development of best practices in this patient population. This article provides a review of the current literature regarding optimal management of patients suffering from shoulder instability with concomitant hyperlaxity of the shoulder, from isolated shoulder joint hyperlaxity to congenital hypermobility spectrum disorders (HSD).

RECENT FINDINGS

Current research shows specialized physiotherapy protocols focused on strengthening of periscapular muscles and improvement of sensorimotor control are a promising non-surgical therapeutic avenue in certain patients, which can be augmented by device-based intervention in select cases. If surgical treatment is warranted, arthroscopic techniques such as pancapsular shift or plication continue to demonstrate favorable outcomes and are currently considered the benchmark for success. The long-term success of more recent innovations such as coracoid process transfers, conjoint tendon transfers, subscapularis tendon augmentation, and capsular reconstruction remains unproven. For patients affected by connective tissue disorders, treatment success is generally less predictable, and the entire array of non-operative and operative interventions needs to be considered to achieve the best patient-specific treatment results. In the treatment of shoulder instability and concomitant hyperlaxity, specialized physiotherapy protocols augmented by device-based interventions have emerged as powerful, non-operative treatment options for select patients. Successful surgical approaches have been demonstrated to comprehensively address capsular redundancy, labral lesions, and incompetence of additional passive stabilizers in a patient-specific fashion, respective of the underlying connective tissue constitution.

The association between number of shoulder diagnoses and positive clinical tests with self-reported function and pain: A cross-sectional study of patients with hypermobile joints and shoulder complaints

BACKGROUND

Patients with hypermobility spectrum disorder (HSD) and shoulder complaints may suffer from symptoms related to shoulder instability, laxity, and hypermobility. It is currently unknown whether having a more complex clinical status with several diagnoses (i.e., anterior instability (AI), multidirectional instability (MDI), and/or symptomatic localised shoulder hypermobility (LSH), relates to higher functional impairments and pain.

OBJECTIVES

To investigate the associations between either ≤1, 2, or 3 clinical shoulder diagnoses (AI, MDI, and LSH) or the number (0-10) of positive clinical shoulder tests with shoulder function using the western Ontario shoulder instability index (WOSI, 0-2100, 0 = best) and pain intensity using numerical pain rating scale (NPRS, 0-10, 10 = worse).

DESIGN

Exploratory cross-sectional study.

METHOD

From a randomised controlled trial, baseline data from 100 participants with HSD and shoulder complaints for at least three months were included. Associations were investigated using linear regression models, adjusted for age, sex, body mass index, and hand dominance.

RESULTS

Compared with having ≤1 diagnosis, neither participants with two (WOSI 76.9, 95% CI -136.3, 290.0; NPRS 0.3, 95% CI -0.9, 1.5) nor three (WOSI 35.5, 95% CI -178.5, 249.6; NPRS 0.1, 95% CI -1.1, 1.3) clinical shoulder diagnoses had significantly worse shoulder function or pain. Likewise, the number of positive clinical shoulder tests was not associated with function (WOSI -20.8 95%CI (-55.3, 13.7)) or pain (NPRS -0.1 95%CI (-0.2, 0.1)).

CONCLUSIONS

In participants with HSD and shoulder complaints, having more additional shoulder diagnoses or increased number of positive shoulder tests were not related to functional impairments or pain intensities.

Rationale and Feasibility of Resistance Training in hEDS/HSD: A Narrative Review

Hypermobile Ehlers-Danlos Syndrome (hEDS) and hypermobility spectrum disorder (HSD) are genetic conditions characterized by increased joint hypermobility, often in the presence of other signs or symptoms if syndromic. This hypermobility can result in significant pain and ultimately decreased participation in recreational or competitive activity. Rehabilitation of patients with hEDS/HSD is not well understood, particularly since presentation can be relatively heterogenous. Regardless, more research is needed, particularly regarding resistance training, to allow patients with hEDS/HSD to participate in the activities they enjoy. The purpose of this narrative review is to provide an overview of the clinical features displayed by those with hEDS/HSD that have been found to be improved with resistance training in other populations, and to present the current evidence for resistance training in all types of study designs, ranging from case studies to randomized controlled trials.

Are progressive shoulder exercises feasible in patients with glenohumeral osteoarthritis or rotator cuff tear arthropathy?

BACKGROUND

Little is known about the feasibility of progressive shoulder exercises (PSE) for patients with glenohumeral osteoarthritis (OA) or rotator cuff tear arthropathy (CTA). The aim of this study was to investigate whether 12 weeks of PSE is feasible in patients with glenohumeral OA or CTA eligible for shoulder arthroplasty. Moreover, to report changes in shoulder function and range of motion (ROM) following the exercise program.

METHODS

Twenty patients were included. Eighteen patients (11 women, 15 with OA), mean age 70 years (range 57-80), performed 12 weeks of PSE with one weekly physiotherapist-supervised and two weekly home-based sessions. Feasibility was measured by dropout rate, adverse events, pain, and adherence to PSE. At baseline and end of intervention, patients completed the Western Ontario Osteoarthritis of the Shoulder (WOOS) score and Disabilities of the Arm, Shoulder and Hand (DASH). Data to assess feasibility were analyzed using descriptive statistics.

RESULTS

Two patients dropped out and no adverse events were observed. Sixteen of the eighteen patients (89%) had a high adherence (≥ 70%) to the physiotherapist-supervised sessions. Acceptable pain levels were reported; in 76% of all exercise sessions with no numeric rating scale (NRS) score over five for any exercise. WOOS improved with a mean of 23 points (95% CI 13;33), and DASH improved with a mean of 13 points (95% CI 6;19).

CONCLUSION

Adherence to PSE was high and dropout rates were low. PSE is feasible, safe and may relieve shoulder pain, improve function and ROM in patients with glenohumeral OA or CTA. The patient-experienced gains after PSE seem clinically relevant and should be compared to arthroplasty surgery in a RCT setting.

TRIAL REGISTRATION

According to Danish law, this study did not need an approval by the Central Denmark Region Committee on Health Research Ethics. Approval from The Danish Data Protection Agency (journal number 1-16-02-15-20) was obtained.

Short-term effectiveness of high-load compared with low-load strengthening exercise on self-reported function in patients with hypermobile shoulders: a randomised controlled trial

OBJECTIVES

To investigate the short-term effectiveness of high-load versus low-load strengthening exercise on self-reported function in patients with hypermobility spectrum disorder (HSD) and shoulder symptoms.

METHODS

A superiority, parallel-group, randomised trial (balanced block randomisation, electronic concealment) including adult patients (n=100) from primary care with HSD and shoulder pain and/or shoulder instability ≥3 months. Patients received 16 weeks of shoulder exercises (three sessions/week): HEAVY (n=50, full-range, high-load, supervised twice/week) or LIGHT (n=50, neutral/mid-range, low-load, supervised three times). The primary outcome was the 16-week between-group difference in self-reported function measured with the Western Ontario Shoulder Instability Index (WOSI, scale 0-2100, 0=best, minimal important difference 252 points). Secondary outcomes were self-reported measures including quality of life and clinical tests including shoulder muscle strength and range of motion. An intention-to-treat analysis with multiple imputation was conducted by a blinded biostatistician using linear regression.

RESULTS

93 of 100 patients (93%) completed the 16-week evaluation. The mean WOSI score between-group difference significantly favoured HEAVY (-174.5 points, 95% CI -341.4 to -7.7, adjusted for age, sex, baseline score, clustering around clinic). The secondary outcomes were inconclusive, but patients in HEAVY were less likely to have a positive shoulder rotation test >180°, and more likely to rate an important improvement in physical symptoms. There were no serious adverse events, but HEAVY was associated with more transient muscle soreness (56% vs 37%) and headaches (40% vs 20%).

CONCLUSION

High-load shoulder strengthening exercise was statistically superior to low-load strengthening exercise for self-reported function at 16 weeks and may be used in primary care to treat patients with HSD and shoulder pain and/or instability to improve shoulder function in the short term. Further studies are needed to confirm the clinical relevance, and patients should be supported to manage associated minor adverse events.

TRIAL REGISTRATION NUMBER

NCT03869307.

Home-based exercise therapy for treating shoulder instability in patients with hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorders. A randomized trial

PURPOSE

To investigate the effectiveness of two home-based exercise programs for treating multidirectional shoulder instability (MDI) in patients diagnosed with Hypermobile Ehlers-Danlos syndrome (hEDS) or Hypermobility Spectrum Disorders (HSD).

METHODS

Twenty-one hEDS/HSD patients with MDI were recruited from the Center for Medical Genetics of the Ghent University Hospital. Patients were randomly assigned to either the experimental or the control group. Both groups received a 6-month home-based exercise program. The primary outcome measure was the Western Ontario Shoulder Index (WOSI). Secondary outcomes included the Disabilities of the Arm, Shoulder and Hand (DASH), Tampa Scale for Kinesiophobia (TSK), Patient-Specific Functional Scale (PSFS), Global Rating of Change (GROC), and pain pressure thresholds. Outcomes were assessed at baseline, after 6 weeks, 12 weeks, and 24 weeks.

RESULTS

Significant main effects for time were observed for all questionnaires, except for the TSK (p = 0.12). Patients improved 240 and 325 points on the WOSI after 12 (p = 0.02) and 24 weeks (p = 0.001), respectively. Additionally, patients improved 8.6 points on the DASH (p = 0.002), 4.3 points on the PSFS (p = 0.01), and 1.02 points on the GROC (p = 0.001) after 24 weeks.

CONCLUSION

No significant differences were found between group A and B. Both home-based exercise programs led to significant improvements in shoulder function. IMPLICATIONS FOR REHABILITATIONHome-based exercise therapy may be effective for treating MDI in the hEDS/HSD population.Home-based training is beneficial for improving shoulder function, but a multidisciplinary, supervised approach might be more effective for altering kinesiophobia in this patient population.

The Effectiveness of Proprioceptive Training for Improving Motor Performance and Motor Dysfunction: A Systematic Review

Objective

Proprioceptive training is any intervention aiming to improve proprioceptive function with the ultimate goal to enhance motor function and performance. It has been promoted as an approach to enhance athletic performance and as a tool for sensorimotor rehabilitation. Numerous studies sought to provide evidence on the effectiveness of the approach. However, many different training regimes claiming to train proprioception report a variety of sensorimotor measures that are not directly comparable. This, in turn, makes it difficult to assess effectiveness across approaches. It is the objective of this study to systematically review recent empirical evidence to gain an understanding of which outcome measures are most sensitive, which populations may benefit most from proprioceptive training, and what are the effects on proprioceptive and motor systems.

Methods

Four major databases were searched. The following inclusion criteria were applied: (1) A quantified pre- and post-treatment measure of proprioceptive function. (2) An intervention or training program believed to influence or enhance proprioceptive function. (3) Contained at least one form of treatment or outcome measure that is indicative of somatosensory function and not confounded by information from other sensory modalities. 4) The study reported of at least one quantified measure of motor performance.

Results

Of the 3,297 articles identified by the database search, 70 studies met the inclusion criteria and were included for further review. Across studies, proprioceptive training led to comparable gains in both proprioceptive (+46%) and motor performance (+45%). The majority of studies (50/70) applied active movement interventions. Interventions applying somatosensory stimulation were most successful in clinical populations. Joint position sense error (JPSE) was the most commonly used proprioceptive measure and presents a reliable and feasible measure for clinical use.

Conclusion

Proprioceptive training can lead to significant improvements in proprioceptive and motor function across a range healthy and clinical populations. Regimens requiring active movement of the trainee tended to be most successful in improving sensorimotor performance. Conclusive evidence on how long training gains are retained is still lacking. There is no solid evidence about the underlying long-term neuroplastic changes associated proprioceptive training.

Exercise and rehabilitation in people with Ehlers-Danlos syndrome: A systematic review

Objective

Data Sources

Study Selection

Data Extraction

Data Synthesis

Conclusions

Clinical Characteristics of 100 Patients with Hypermobility Spectrum Disorders and Shoulder Complaints With or Without Mechanical Symptoms: A Cross-Sectional Study

OBJECTIVE

The aims were to describe the clinical characteristics of patients with hypermobility spectrum disorders (HSD) and shoulder complaints with or without mechanical symptoms, and to compare characteristics between these groups.

DESIGN

Descriptive study.

SETTING

Primary care PARTICIPANTS: One-hundred patients with HSD and shoulder complaints for at least three months were included from primary care.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Medical history, self-reported (shoulder pain and function, discomfort due to other symptoms, fatigue, fear of movement, quality of life) and objective (strength, range of motion, proprioception) characteristics were collected by physiotherapists. Mechanical symptoms (Yes/No) were defined as self-reported shoulder instability, subluxation, and/or laxity.

RESULTS

Sixty-seven reported mechanical symptoms. Patients in both groups reported impairments related to shoulder pain, function, fatigue, fear of movement, and quality of life. Patients with mechanical symptoms were younger (mean (95% CI): 35.1 (32.3; 37.9) vs. 43.3 (38.4; 48.1) years), had longer symptom duration (median: 46 (36; 66) vs. 24 (9; 56) months), reported a previous shoulder dislocation (25% (16; 37) vs. 3% (0; 16)), experienced that their shoulder was loose (64% (52; 76) vs. 15% (5; 32)), and reported discomfort due to other symptoms (OR 1.48 (1.17; 1.87)). Furthermore, a larger proportion had received supplemental treatment (analgesic medication, steroid injection/surgery).

CONCLUSION(S)

Both groups with HSD and shoulder complaints presented with substantial shoulder-related impairments. Two-thirds reported mechanical symptoms, were younger, and more severely impaired than those without mechanical symptoms. These findings highlight the importance of managing mechanical shoulder symptoms to fully address the patients' impairments.

Practical management strategies for benign hypermobility syndromes

PURPOSE OF REVIEW

Patients with symptomatic hypermobility syndrome such as hypermobile Ehlers-Danlos syndromes (hEDS) and hypermobility spectrum disorders (HSD) commonly present to rheumatologists with joint pain and functional disability. Providers often have difficulty with diagnosis due to a lack of knowledge on the range of associated manifestations and the available therapeutic modalities. This review will discuss recent updates on diagnostic measures and treatment options for rheumatologists to help patients navigate hEDS/HSD.

RECENT FINDINGS

This article describes newer diagnostic measures and assessment of hEDS/HSD manifestations. Evidence supporting physical therapy and occupational therapy is provided, as well as recent updates on assistive devices, compressive garments, orthoses, and surgical interventions. Given patient heterogeneity specific guidance about the amount and type of therapies required to produce a beneficial effect is lacking. Treatment should be individualized, and many of the studies focus on regional joint complaints rather than a whole-body approach.

SUMMARY

Physical therapy and occupational therapy remain the cornerstone of treatment.

Effect of resistance training on muscle properties and function in women with generalized joint hypermobility: a single-blind pragmatic randomized controlled trial

Background

Generalized joint hypermobility is defined as an excessive range of motion in several joints. Having joint hypermobility is not a pathology, but when associated with pain and other symptoms, it might affect health and function. Evidence for physiotherapy management is sparse and resistance training might be a possible intervention. Thus, the effects of 12-week resistance-training on muscle properties and function in women with generalized joint hypermobility were evaluated.

Methods

In this single-blind randomized controlled trial women between 20 and 40 years with generalized joint hypermobility (Beighton score at least 6/9) were included. Participants were randomly allocated to 12-week resistance training twice weekly (experimental) or no lifestyle change (control). Resistance training focused on leg and trunk muscles. Primary outcome was muscle strength; additional outcomes included muscle properties, like muscle mass and density, functional activities, pain and disability. Training adherence and adverse events were recorded.

Results

Of 51 participating women 27 were randomised to training and 24 into the control group. In each group 11 women had joint hypermobility syndrome, fulfilling the Brighton criteria, while 24 (89%) in the training group and 21 (88%) in the control group mentioned any pain. The mean strength of knee extensors varied in the training group from 0.63 (sd 0.16) N/bm before training to 0.64 (sd 0.17) N/bm after training and in the control group from 0.53 (sd 0.14) N/bm to 0.54 (sd 0.15) N/bm. For this and all other outcome measures, no significant differences between the groups due to the intervention were found, with many variables showing high standard deviations. Adherence to the training was good with 63% of participants performing more than 80% of sessions. One adverse event occurred during training, which was not clearly associated to the training. Four participants had to stop the training early.

Conclusions

No improvement in strength or muscle mass by self-guided resistance training was found. Low resistance levels, as well as the choice of outcome measures were possible reasons. A more individualized and better guided training might be important. However, program adherence was good with few side effects or problems triggered by the resistance training.

Trial registration

This trial was prospectively registered in the ISRCTN registry (www.isrctn.com, BMC, Springer Nature) on July 16, 2013 as ISRCTN90224545. The first participant was enrolled at October 25, 2013.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00238-8.

A randomised controlled trial of heavy shoulder strengthening exercise in patients with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome and long-lasting shoulder complaints: study protocol for the Shoulder-MOBILEX study

Background

Four out of five patients with hypermobility spectrum disorder (HSD) or hypermobile Ehlers-Danlos syndrome (hEDS) experience shoulder complaints including persistent pain and instability. Evidence suggests that patients with HSD/hEDS who experience knee and back complaints improve with exercise-based therapy. However, no study has focused on exercise-based treatment for the shoulder in this patient group. The potential benefits of strengthening the shoulder muscles, such as increased muscle-tendon stiffness, may be effective for patients with HSD/hEDS who often display decreased strength and increased shoulder laxity/instability.

The primary aim is to investigate the short-term effectiveness of a 16-week progressive heavy shoulder strengthening programme and general advice (HEAVY) compared with low-load training and general advice (LIGHT), on self-reported shoulder symptoms, function, and quality of life.

Methods

A superiority, parallel group, randomised controlled trial will be conducted with 100 patients from primary care with HSD/hEDS and shoulder complaints (persistent pain and/or instability) for more than 3 months. Participants will be randomised to receive HEAVY (full range of motion, high load) or LIGHT (neutral to midrange of motion, low load) strengthening programme three times weekly with exercises targeting scapular and rotator cuff muscles. HEAVY will be supervised twice weekly, and LIGHT three times during the 16 weeks. The primary outcome will be between-group difference in change from baseline to 16-week follow-up in the Western Ontario Shoulder Instability Index (WOSI, 0-2100 better to worse). Secondary outcomes will include a range of self-reported outcomes covering symptoms, function, and quality of life, besides clinical tests for shoulder strength, laxity/instability, and proprioception. Outcome assessors will be blinded to group allocation. Participants will be kept blind to treatment allocation through minimal information about the intervention content and hypotheses. Primary analyses will be performed by a blinded epidemiologist.

Discussion

If effective, the current heavy shoulder strengthening programme will challenge the general understanding of prescribing low-load exercise interventions for patients with HSD/hEDS and provide a new treatment strategy. The study will address an important and severe condition using transparent, detailed, and high-quality methods to potentially support a future implementation.

Trial registration

ClinicalTrials.gov NCT03869307. Registered on 11 March 2019.

Supplementary information

The online version contains supplementary material available at 10.1186/s13063-020-04892-0.