Physiotherapy sessions offer no benefits over general advice for patients with a dislocated shoulder

Study sheds light on neglected research topic

Despite the important role played by rehabilitation for this common condition (the shoulder is the most frequently dislocated joint), evidence comparing different rehabilitation methods after the initial period in a sling is scarce, the article states. Internationally, guideline recommendations range from 'advice only' to advice and an additional programme of supervised physiotherapy.

The authors point out that the choice of rehabilitation offered following a shoulder dislocation has 'large resource implications' for participants and health care providers alike. For example, younger people may need to take time off work or arrange care for dependents while older people may find travel challenging – particularly if they are unable to drive following the dislocation.

Consequently, if a single advice session were all that is required, the burden on patients and the healthcare resources required would lessen. Considering the large personal and societal cost associated with this injury, the primary objective of the ARTISAN trial (see link below for more information) was to compare the clinical effectiveness of two rehabilitation interventions in adults with a first time traumatic shoulder dislocation.

Hundreds of NHS staff contributed to the study

Non-operative management is the most common treatment after a first dislocation. This can range from an advice sheet only to a programme of individually tailored physiotherapy over several months, but no previous trial evidence is available to inform the best approach.

To explore this further, researchers set out to assess the effects of two rehabilitation interventions in adults with a first-time traumatic shoulder dislocation at 40 NHS hospitals in the UK from November 2018 to March 2022. Hundreds of NHS staff made a contribution, and their names are listed at the end of the article.

Every participant (66 per cent of whom were male, with an average age of 45 years) initially had their arm supported in a sling and received a physiotherapy advice session within six weeks of their injury, which included a shoulder examination plus advice and support materials to aid self-management.

After this session, 240 participants were randomly assigned to advice only (no further treatment) and 242 were offered additional physiotherapy sessions, each lasting for up to 30 minutes over four months.

The main measure of interest was shoulder function on the Oxford shoulder instability score (a 0-48-point scale) reported by patients after six months.

No clinically relevant differences in shoulder scores were found between the two groups at six months or in other measures, including a questionnaire on physical function of the arm, shoulder and hand. Complications were also similar across the two groups, the authors note. 

Knowing that an individually tailored programme of physiotherapy is not superior will enable clinicians and patients to have evidenced informed discussions about the best approach to non-operative rehabilitation [Rebecca Kearney et al]

Conclusions

This is the largest trial on the topic to date, Professor Kearney and her colleagues state. While acknowledging that just over a quarter of the participants were lost to follow up, they note that further analysis – accounting for missing data – gave similar results. This reassured them that the conclusions were robust.

As such they say that, until now, no strong evidence was available to guide rehabilitation management following an initial two weeks support in a sling. ‘We now know an additional programme of individually tailored physiotherapy is not superior to advice, supporting materials, and an option to self-refer to physiotherapy.'

Professor Kearney and her 11 co-writers add: ‘Knowing that an individually tailored programme of physiotherapy is not superior will enable clinicians and patients to have evidenced informed discussions about the best approach to non-operative rehabilitation.'

What this study adds

• ARTISAN is the largest trial on this topic to date, recruiting 482 participants from 40 sites in the UK
• an individually tailored programme of physiotherapy compared with a single session of advice, supporting materials, and option to self-refer to physiotherapy did not significantly improve function six months after treatment
• knowing that an individually tailored programme of physiotherapy is not superior will enable clinicians and patients to have evidenced, informed discussions about the best approach to non-operative rehabilitation

The National Institute for Health and Care Research provided funding for the study

The trial was called Acute Rehabilitation following Traumatic anterior shoulder dISlocAtioN (ARTISAN): A Multi Centre Randomised Controlled Trial. For more information, click

To read the full version of the article – titled Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomised controlled trial doi: 10.1136/bmj-2023-076925 – click

Linked editorial

The randomised clinical trial was well planned, executed, and reported, say two New Zealand-based physiotherapist researchers –Margie Olds and Gisela Sole – in a linked editorial. The results show that physiotherapy-led rehabilitation, including generalised range of movement and strengthening exercises (mainly below shoulder height), plus patient advice, confers minimal advantage over advice and education alone. 

However, Dr Olds and Professor Sole warn readers to be cautious about extrapolating from the results, particularly in relation to younger patients wishing to return to sports, occupations, or activities with high shoulder loads.

Margie Olds is based at Flawless Motion, Auckland, and Gisela Sole is based at the Centre of Health, Activity and Rehabilitation Research in the School of Physiotherapy, University of Otago, Dunedin

To read the full version of the editorial – titled Acute rehabilitation after traumatic shoulder dislocation doi: 10.1136/bmj.q21 – click