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AbstractObjectiveTo assess the effects of an additional programme of physiotherapy in adults with a first-time traumatic shoulder dislocation compared with single session of advice, supporting materials, and option to self-refer to physiotherapy.DesignPragmatic, multicentre, randomised controlled trial (ARTISAN).Setting and participantsTrauma research teams at 41 UK NHS Trust sites screened adults with a first time traumatic anterior shoulder dislocation confirmed radiologically, being managed non-operatively. People were excluded if they presented with both shoulders dislocated, had a neurovascular complication, or were considered for surgical management.InterventionsOne session of advice, supporting materials, and option to self-refer to physiotherapy (n=240) was assessed against the same advice and supporting materials and an additional programme of physiotherapy (n=242). Analyses were on an intention-to-treat basis with secondary per protocol analyses.Main outcome measuresThe primary outcome was the Oxford shoulder instability score (a single composite measure of shoulder function), measured six months after treatment allocation. Secondary outcomes included the QuickDASH, EQ-5D-5L, and complications.Results482 participants were recruited from 40 sites in the UK. 354 (73%) participants completed the primary outcome score (n=180 allocated to advice only, n=174 allocated to advice and physiotherapy). Participants were mostly male (66%), with a mean age of 45 years. No significant difference was noted between advice compared with advice and a programme of physiotherapy at six months for the primary intention-to-treat adjusted analysis (between group difference favouring physiotherapy 1.5 (95% confidence interval −0.3 to 3.5)) or at earlier three month and six week timepoints. Complication profiles were similar across the two groups (P>0.05).ConclusionsAn additional programme of current physiotherapy is not superior to advice, supporting materials, and the option to self-refer to physiotherapy.Trial registrationCurrent Controlled Trials ISRCTN63184243.

Anterior shoulder dislocation is a common orthopedic emergency. While many reduction methods require sedation, the FARES (FAst, REliable, and Safe) and Spaso methods allow reduction without anesthesia. We conducted a single-center, prospective, randomized controlled trial comparing the FARES and Spaso methods for anterior shoulder dislocation reduction. Patients aged 20 to 90 years were enrolled. The assigned closed reduction procedures were performed without patient sedation by trained orthopedic residents. If two attempts with the assigned method failed, the alternative method was used. The primary outcome was the first-attempt success rate, while secondary outcomes included overall success rate with both methods, reduction time, and pain scores. During November 2013 and December 2015, a total of 32 patients were randomized to the FARES (n = 17) or Spaso (n = 15) method. The first-attempt success rates were 71.6% for the FARES group and 80.0% for the Spaso group ( p  = 0.691). Among patients with failed closed reduction using the first technique, all patients in the Spaso-following-FARES group achieved successful reduction, whereas none in the FARES-following-Spaso group achieved successful reduction ( p  = 0.092). Pain scores during reduction were comparable between the FARES (4.29 ± 1.69) and Spaso (3.80 ± 2.65) techniques, with no statistically significant difference ( p  = 0.542). Follow-up data were available for 28/32 patients (87.5%; mean 5.3 ± 2.2 years). Four patients were lost (3 FARES, 1 Spaso; p  = 0.726). Recurrent dislocation occurred in 3 patients (10.7%; 1 FARES, 2 Spaso; p  = 0.947), and 2 patients (1 per group; p  = 0.876) underwent surgery (arthroscopic stabilization and rotator cuff repair). Both the FARES and Spaso methods were effective for reducing anterior shoulder dislocations. Combining these methods may improve overall reduction rates. Clinical trial registration: This trial was registered at ClinicalTrials.gov (Registration number: NCT01979237) on 08/11/2013.

The principal aim of this study was to present a novel approach to manipulative repositioning for the management of anterior shoulder dislocation. This was evaluated in comparison with the established repositioning method to ascertain its clinical efficacy. Seventy-six patients with anterior dislocation of the shoulder joint were randomly assigned to one of two groups. Each group underwent reducing using either Tang’s method or Hippocrates’ method, respectively. The patients were then monitored for six months. The researchers analyzed and compared the general condition, reduction time, reduction success rate, VAS score, and ASES score of the patients in the two groups. No statistically significant difference was observed in the general condition of the patients prior to the reduction between the two groups. The mean reduction time for the Tang’s method group (70.9 ± 11.88) was found to be significantly shorter than that observed for the Hippocrates method group (411.6 ± 50.41). The reduction success rate was significantly higher in the Tang’s method group (100.00%) than in the Hippocrates method group (80.56%). No statistically significant difference was observed in VAS scores between the two groups prior to the reduction. However, the Tang’s method group demonstrated superior outcomes compared to the Hippocrates method group during and following the reduction. No statistically significant difference was observed in ASES scores between the two groups prior to the reduction. However, at one, three, and six months post-reduction, the Tang’s method group exhibited significantly superior outcomes compared to the Hippocrates method group. The Tang’s method is a safe and effective method of reducing for anterior dislocation of the shoulder. It is significantly superior to the traditional Hippocrates method.

Background The traditional treatment for primary anterior shoulder dislocations has been immobilization in a sling with the arm in a position of adduction and internal rotation. However, recent basic science and clinical data have suggested recurrent instability may be reduced with immobilization in external rotation after primary shoulder dislocation. Questions/purposes We performed a randomized controlled trial to compare the (1) frequency of recurrent instability and (2) disease-specific quality-of-life scores after treatment of first-time shoulder dislocation using either immobilization in external rotation or immobilization in internal rotation in a group of young patients. Methods Sixty patients younger than 35 years of age with primary, traumatic, anterior shoulder dislocations were randomized (concealed, computer-generated) to immobilization with either an internal rotation sling (n = 29) or an external rotation brace (n = 31) at a mean of 4 days after closed reduction (range, 1–7 days). Patients with large bony lesions or polytrauma were excluded. The two groups were similar at baseline. Both groups were immobilized for 4 weeks with identical therapy protocols thereafter. Blinded assessments were completed by independent observers for a minimum of 12 months (mean, 25 months; range, 12–43 months). Recurrent instability was defined as a second documented anterior dislocation or multiple episodes of shoulder subluxation severe enough for the patient to request surgical stabilization. Validated disease-specific quality-of-life data (Western Ontario Shoulder Instability index [WOSI], American Shoulder and Elbow Surgeons evaluation [ASES]) were also collected. Ten patients (17%, five from each group) were lost to followup. Reported compliance with immobilization in both groups was excellent (80%). Results With the numbers available, there was no difference in the rate of recurrent instability between groups: 10 of 27 patients (37%) with the external rotation brace versus 10 of 25 patients (40%) with the sling redislocated or developed symptomatic recurrent instability (p = 0.41). WOSI scores were not different between groups (p = 0.74) and, although the difference in ASES scores approached statistical significance (p = 0.05), the magnitude of this difference was small and of uncertain clinical importance. Conclusions Despite previous published findings, our results show immobilization in external rotation did not confer a significant benefit versus sling immobilization in the prevention of recurrent instability after primary anterior shoulder dislocation. Further studies with larger numbers may elucidate whether functional outcomes, compliance, or comfort with immobilization can be improved with this device. Level of Evidence Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

To evaluate the effect of the Milch technique on quality of life (QoL) in patients with anterior dislocation of the shoulder joint. A total of 126 patients undergoing manual reduction for anterior dislocation of the shoulder in our hospital from January 2021 to January 2022 were prospectively enrolled in this study. The randomized number table method was used to divide patients into the study group (63 patients) and the control group (63 patients). The study group was treated with a modified Milch technique while the control group was treated with the Hippocratic method. Success rate and complications were compared to evaluate the effectiveness of manual reduction. Clinical assessment of shoulder function included the Constant-Murley Score and visual analog scale (VAS) before, during and after manual reduction. The success rate of primary and secondary reduction in the study group was significantly higher than in the control group (87.30% vs 61.90, respectively; P = .001; 11.11% vs 25.40%, respectively; P = .038). The failure rate in the study group was significantly lower than in the control group (1.59% vs 12.70%, respectively; P = .015). The time required for reduction in the study and control groups was 58.87 ± 7.92 seconds and 93.09 ± 8.01 seconds, respectively; a significant difference (t = -24.113; P < .001). There was no statistically significant difference in VAS scores before and during reduction in the 2 groups. After reduction, VAS scores in the study group were significantly lower than in the control group (1.02 ± 0.01 vs 1.14 ± 0.26, respectively; P < .001). There were no significant differences in pain level, activities of daily living, joint range of motion or muscle strength between the 2 groups before and after reduction (P > .05). After reduction, health status, emotional function, mental health, physiological function, physiological function, physical pain, vitality and social function scores in the study group were significantly higher than in the control group (P < .05). There were 4 avulsion fractures and 2 humeral fractures in the control group; no complications occurred in the study group, with a significant difference (χ2 = 6.289; P = .012). The Milch technique can improve the QoL in patients with anterior dislocation of the shoulder, and the success rate of the reduction is high.

Background and Objectives: We investigated the effects of sling-suspension-based active shoulder joint exercise training on shoulder joint subluxation, pain, muscle strength, and upper extremity function in patients with subacute stroke. Materials and Methods: Twenty-eight patients with subacute stroke were randomly assigned to either the sling-suspension-based active shoulder joint exercise (SASE) group (n = 14) or the motorized upper extremity exercise (MUEE) group (n = 14). The SASE group actively performed shoulder joint flexion, extension, abduction, adduction, external and internal rotation, and horizontal abduction and adduction using a sling suspension system, whereas the MUEE group underwent an exercise program using a motorized upper extremity exercise machine. All participants underwent a 4-week intervention with 30 min of exercise once a day for 5 days a week. Additionally, both groups received general physical therapy and functional electrical stimulation for 30 min twice a day for 5 days a week. Shoulder joint subluxation was measured by radiographic examination before and after training, and pain was evaluated in the splenius, upper trapezius, and infraspinatus muscles using pressure parameters. In addition, a manual muscle tester was used to assess the muscle strength of the shoulder joint flexors, extensors, abductors, adductors, and external and internal rotators, and the Fugl–Mayer Assessment (FMA) and Manual Functional Test (MFT) were used to evaluate upper extremity function. Results: A significant group–time interaction was observed for pain, with F-values of F(1, 26) = 7.470, p < 0.011 for the splenius and F(1, 26) = 9.623, p < 0.005 for the upper trapezius. A significant time–group interaction was observed for the muscle strength of the shoulder, with F-values of F(1, 26) = 13.211, p < 0.001; F(1, 26) = 4.974, p = 0.035 and F(1, 26) = 9.674, p = 0.004 for flexors, abductors, and external rotators, respectively. A significant time–group interaction was observed in the FMA, with F-values of F(1, 26) = 13.243, p < 0.001. When comparing the interaction effects between time and group for MFT scores, a significant difference was observed, with F-values of F(1, 26) = 32.386, p < 0.001. Conclusions: This study confirmed that sling-suspension-based active shoulder joint exercises are effective in improving shoulder joint subluxation, pain, muscle strength, and upper extremity function in patients with subacute stroke.

Few studies were performed to compare ultrasound guided brachial plexus block with procedural sedation for reduction of shoulder dislocations in the Emergency Department (ED). This study was done to provide further evidence regarding this comparison. This was a randomized clinical trial performed on patients presenting with anterior shoulder dislocations to the emergency department of an academic level 2 trauma center. Exclusion criteria were any contraindications to the drugs used, any patient which may not be potentially assigned into both groups because of an underlying medical condition, presence of neurovascular compromise related to the dislocation, presence of concomitant fractures, and patient refusal to participate in the study. Patients were randomly assigned into the Procedural Sedation and Analgesia (PSA) group with propofol and fentanyl or ultrasound guided Inter-Scalene Brachial Plexus Block (ISBPB) with lidocaine and epinephrine. A total of 60 patients (30 in each group) were included in the study. The emergency room length of stay was significantly lower in the ISBPB group, with mean (SD) values of 108.6 (42.1) vs. 80.2 (25.2) minutes (p=0.005). However, pain scores in the PSA group during reduction showed advantage over ISBPB [0.38 vs. 3.43 (p<0.001)]. Moreover, patient satisfaction was higher with PSA (p<0.001). Using ISBPB for reduction of anterior shoulder dislocations takes less time to discharge and may make it more feasible in conditions mandating faster discharge of the patient. However, since pain scores may be lower using PSA, this method may be preferred by many physicians in some other situations.

IntroductionAnterior shoulder dislocation is a common reason for consultation at the emergency department (ED). Hypnosis could be a safe and effective alternative therapy for pain relief during shoulder dislocation reduction but nowadays, evidence is not sufficient. The main objective of this study is to show that reduction under hypnosis is associated with a decrease in the use of analgesic compared with usual care.Methods and analysisWe will conduct an interventional, controlled, multicentre, randomised study. A total of 44 patients with shoulder dislocation will be randomised in two groups: the hypnosis group (N=22) and the usual care group (N=22). The primary endpoint will be the comparison of morphine equivalent analgesic consumption during a shoulder dislocation reduction manoeuvre. Secondary endpoints will include haemodynamic parameters monitoring, patient and practitioner satisfaction using a Likert scale, use of coanalgesic or sedative drugs, number of reduction attempts and time spent at ED. Adverse events will be recorded. Statistical analysis will include parametric tests, multivariate linear regression and descriptive statistics.Ethics and disseminationThis study has received ethics approval from the Comité de Protection des Personnes of Sud-Est IV on 03/11/2021 (ANSM informed on 19 November 2021). The results will be published in scientific articles and communicated in national and international conferences.Trial registration numberClinicalTrial.gov: NCT04992598; National Clinical trial no ID RCB : 2021-A01382-39

Dislocation of the shoulder joint is one of the most common dislocations. The reduction procedure is a painful procedure. In this study, 2 different treatment groups were compared for pain control during shoulder dislocation reduction. It was aimed to evaluate the differences between the groups in reduction, success, length of hospital stay, complications, side effects, patient-physician satisfaction, and ease of application. The study was planned to be prospective and randomized. As procedural sedation analgesia (SA), titration of ketamine 1 to 2 mg/kg was administered intravenously to group 1. Suprascapular nerve block (SNB) was applied under ultrasound guidance (USG) to group 2. Conformity to normal distribution of variables was examined with the Kolmogorov-Smirnov test. The χ2 test and Fisher test were used to evaluate differences between the groups in categorical variables and the Mann-Whitney U test, and a value of P < .05 was accepted as statistically significant. The study comprised a total of 41 patients; 20 in the group 1 and 21 in the group 2. No statistically significant difference was determined between the groups in terms of age (P = .916), sex (P = .972), reduction success (P = .540), and patient-physician satisfaction (P = .198). The time spent in the emergency department (ED) by patients in the SA group was signficantly longer compared with the SNB group. No side effects were observed in the SNB group. Suprascapular nerve block, which can be easily applied under USG in the ED, can be evaluated as a good alternative to SA in the reduction of shoulder dislocations.

IntroductionGlenohumeral (shoulder) dislocations are the most common large joint dislocations seen in the emergency department (ED). They cause pain, often severe, and require timely interventions to minimise discomfort and tissue damage. Commonly used reposition or relocation techniques often involve traction and/or leverage. These techniques have high success rates but may be painful and time consuming. They may also cause complications. Recently, other techniques—the biomechanical reposition techniques (BRTs)—have become more popular since they may cause less pain, require less time and cause fewer complications. To our knowledge, no research exists comparing the various BRTs. Our objective is to establish which BRT or BRT combination is fastest, least painful and associated with the lowest complication rate for adult ED patients with anterior glenohumeral dislocations (AGDs).Methods and analysisAdults presenting to the participating EDs with isolated AGDs, as determined by radiographs, will be randomised to one of three BRTs: Cunningham, modified Milch or scapular manipulation. Main study parameters/endpoints are ED length of stay and patients’ self-report of pain. Secondary study parameters/endpoints are procedure times, need for analgesic and/or sedative medications, iatrogenic complications and rates of successful reduction.Ethics and disseminationNon-biomechanical AGD repositioning techniques based on traction and/or leverage are inherently painful and potentially harmful. We believe that the three BRTs used in this study are more physiological, more patient friendly, less likely to cause pain, more time efficient and less likely to produce complications. By comparing these three techniques, we hope to improve the care provided to adults with acute AGDs by reducing their ED length of stay and minimising pain and procedure-related complications. We also hope to define which of the three BRTs is quickest, most likely to be successful and least likely to require sedative or analgesic medications to achieve reduction.Trial registration numberNTR5839.