clinical evaluation of muscle function, quality of life and functional capacity after shoulder...
TRANSCRIPT
Correspondence: Sofi a Ryman Augustsson, PhD, RPT, Lundberg Laboratory for Orthopaedic Research, Department of Orthopaedics, Sahlgrenska University Hospital, SE-413 45 G ö teborg, Sweden. E-mail: sofi [email protected]
(Received 9 June 2011 ; accepted 23 January 2012 )
compared with women (2). A sensation of instability and distrust in the stability and capacity of the shoulders are leading to lower levels of sporting activities and disuse of the arm (3). Rehabilitation could help an athlete with a shoulder dislocation to return to sporting activities within a short period after shoulder dislocation (5,6). However, surgical stabilisation is normally considered for patients who fail to respond to non-surgical treatment. For athletes, a trauma or problems with recurrent instability unfor-tunately often result in the termination of the athlete ’ s sports season. Shoulder instability injuries therefore constantly provide challenges for the physician and
ORIGINAL ARTICLE
Clinical evaluation of muscle function, quality of life and functional capacity after shoulder surgery
SOFIA RYMAN AUGUSTSSON 1,3 , INGRID HULTENHEIM KLINTBERG 1 ,2, 3 , ULLA SVANTESSON 2,3 & NINNI SERNERT 1,4
1 The Institute of Clinical Sciences/Department of Orthopaedics, Sahlgrenska Academy at University of Gothenburg, Sweden, 2 Department of Physiotherapy, Sahlgrenska University Hospital, Sweden, 3 Institute of Neuroscience and Physiology/Physiotherapy, Sahlgrenska Academy at University of Gothenburg, Sweden, 4 Department of Research and Development, NU-Hospital Organisation, Trollh ä ttan, Sweden
Abstract The aim of the present study was to analyse and describe muscle function, quality of life and functional capacity before and after shoulder instability surgery. Twenty-six women aged 34 ( � 14) years and 95 men aged 32 ( � 10) years participated in this study. All patients were on the waiting list or had undergone shoulder instability surgery. The study was performed with a cross-sectional design and patients were examined pre-operatively, 6-month post-operatively or 7-year post-operatively. Handgrip strength measurement, active range of motion (AROM), isometric shoulder muscle strength measurement, health-related quality of life measured by Western Ontario Shoulder Instability Index (WOSI © ) and shoulder function using the Constant Score were evaluated. The mean AROM in fl exion for women in all groups ranged from 162 ° ( � 16) to 169 ° ( � 12), and for men from 157 ° ( � 19) to 162 ° ( � 12). The mean AROM in abduction ranged from 170 ° ( � 25) to 177 ° ( � 5) for women and from 177 ° ( � 8) to 179 ° ( � 24) for men. The mean AROM in external rotation ranged from 89 ° ( � 14) to 95 ° ( � 14) for women and from 83 ° ( � 21) to 85 ° ( � 12) for men. Men were signifi cantly stronger and had a larger AROM on the non-injured side compared with the injured side, whereas differences were found between non-injured and injured side for women only in AROM. The scores from the WOSI © for all the patients were far from normative values suggesting that the patient ’ s subjective experience does not fully refl ect the physical examination. The results from the present study can guide the physiotherapist to give patients realistic expectations of shoulder function concerning AROM and muscle strength.
Key words: bankart repair , constant Score , physiotherapy , range of motion , rehabilitation , shoulder instability , shoulder muscle strength , WOSI ©
Introduction
Shoulder instability and shoulder dislocation are common problems in young persons and especially in an athletic population, because of acute or repetitive trauma, in addition to overuse in athletes with liga-mentous laxity (1). The higher the demands imposed by sporting activities, the more likely the athlete is to put the shoulder at risk of traumatic shoulder dislocation (2). Follow-up studies have shown that males more frequently undergo surgical treatment for shoulder instability compared with females (3,4). However, men also appear to put themselves at a higher risk of sustaining shoulder instability injuries
Advances in Physiotherapy, 2012; 14: 29–37
ISSN 1403-8196 print/ISSN 1651-1948 online © 2012 Informa HealthcareDOI: 10.3109/14038196.2012.660988
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instability. The patients were recruited and consecutive selected from the regular pre- and post-examination at the NU-Hospital Organisation. The study was performed with a cross-sectional design. Fifty-six patients were examined pre-operatively (Group I), 34 were examined at the 6-month post-operative evaluation (Group II) and 31 patients were examined at the 7-year post-operative evaluation (Group III). All the groups (Groups I, II and III) were examined in 2004 – 2007. Twenty patients were examined both pre-operatively and at the 6-month post-operative evaluation, and are therefore included in both Groups I and II. Sixty per cent of all the shoulder injuries in the present study occurred during physical activity. Table I gives the characteristics of the patients who participated in the study. Written and verbal informa-tion was given to each patient and written informed consent was obtained. Ethical approval was received from the Human Ethics Committee at Gothenburg University, Sweden.
Assessment and procedure
A special protocol was developed for the pre- and/or post-operative clinical evaluation. One independent observer (physiotherapist), who was not involved in the post-operative rehabilitation, performed all the clinical examinations pre-operatively and at follow-ups 6 months and 7 – 8 years after the index oper-ation. The clinical examinations were performed on both the injured and non-injured side for all patients.
Muscle strength measurement
Handgrip strength . Handgrip strength was measured using the Grippit ® dynamometer (AB Detector, Gothenburg, Sweden), recording both maximum and average (10 s) grip strength values. The Grippit ® is a portable, electronic instrument with a grip device and arm support that enables standardised arm and grip positioning. The grip device allows the fi ngers and palm to be completely clasped around it. The force exerted against the transducer, in the grip
especially for the physiotherapist. A subjective eval-uation of shoulder function in relation to an objec-tive assessment could be important when planning surgical interventions. Additionally, it appears to be vital to document the progress in range of motion, muscle strength, level of sporting and occupational activity as well as patient satisfaction during the period of rehabilitation (7 – 10). In order to set real-istic goals for the patient, a clinical examination, including different aspects of shoulder function, should therefore be of great interest. These perfor-mance-based tests may also form the basis for deci-sion-making related to both further surgical interventions and to physiotherapy intervention in order to restore shoulder stability. Range of motion (10), shoulder muscle strength (11), Constant Score (9) and Western Ontario Shoulder Instability Index (WOSI © ) (12) are measurements that are used in the evaluation after shoulder instability surgery. Although there is a range of commonly used tests, it is not clear which physiotherapy assessments are most useful when evaluating patients with shoulder instability. Thus, it is signifi cant to fi nd standard evaluation protocols in order to follow the patient during rehabilitation, which is an important target in physiotherapy practice.
The aim of the present study was to analyse and describe muscle function, quality of life and func-tional capacity in terms of subjective evaluations scores [WOSI © (7) and the Constant Score (8)] before and after shoulder instability surgery.
Patients and methods
Participants
Twenty-six women aged 34 ( � 14, range 14 – 58) and 95 men aged 32 ( � 10, range 16 – 57) participated in this study. The inclusion criterion was unilateral shoulder instability verifi ed by clinical examination. The exclusion criterion was a re-operation during the post-operative evaluation period. All the patients were on the waiting list or had undergone either an open or an arthroscopic Bankart repair for shoulder
Table I. Patients ’ characteristics by group.
Group I Group II Group III
Mean SD Range Mean SD Range Mean SD Range
Age (years) women 34 13 16 – 58 41 17 24 – 58 33 9 24 – 45Age (years) men 30 9 17 – 47 31 9 17 – 48 37 9 22 – 57Athletes 75% 80% 94%Non-athletes 25% 20% 6%
Values are means, standard deviation, range and percent. Group I (women n � 16, men n � 40), Group II (women n � 3, men n � 31) and Group III (women n � 7, men n � 23).
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Clinical evaluation after shoulder surgery 31
device, is recorded and displayed electronically. The non-injured arm was always measured fi rst and the best value of three was registered. As suggested by Lagerstr ö m & Nordgren (13) and Nordenski ö ld & Grimby (14), a standard grip handle, measuring 45 mm in depth and 27 mm in width, was used for all the patients in the present study. The Grippit ® has shown excellent reliability (15).
Isometric shoulder muscle strength . An Isobex ® dyna-mometer was used to evaluate isometric shoulder muscle strength. The Isobex ® is a portable isometric dynamometer. The patients ’ isometric muscular shoulder strength was measured at 90 ° of lateral elevation, in the plane of the scapula, sitting on a standard chair. The dynamometer was placed on the fl oor, fi xed in place with the suction cups and the band from the dynamometer was placed just proxi-mally to the styloid process of the ulna. During eval-uations of isometric muscular strength in internal and external rotation, the device was fi xed to the wall. The arm was held at the side, the elbow was held in 90 ° of fl exion and the forearm was held in a neutral position of rotation and supination/pronation. The band from the dynamometer was placed just proximally to the styloid process of the ulna. For all the tests, the patients sat with their legs straight and ankles crossed, with the heel of one foot resting on the fl oor. The patients were instructed to keep their trunk in an erect, straight position during the test. The opposite arm hung loosely at the side. The test protocol consisted of three maximum muscle actions held for 5 s in each direction. The trial with the highest force value (kg) for each tested variable was used for the analysis. The Isobex ® has shown high reliability (16).
Range of motion . The measurement of range of motion (ROM) was performed in the sitting posi-tion using a hand-held goniometer graded in one-degree increments. The full active range of motion (AROM) was measured in fl exion and abduction, whereas external rotation was measured in 90 ° of abduction. The non-injured arm was always measured fi rst. The examiner always made a visual check to ensure that the measured value appeared reasonable.
Health-related quality of life . In this study, we used the Western Ontario Shoulder Instability Index (WOSI © ) (17) translated into Swedish by Lillkrona and Nordqvist (Swedish version © ). The WOSI © is a self-administered, disease-specifi c instrument designed to assess patients ’ opinions of quality of life in relation
to shoulder instability. The WOSI © is made up of 21 items. The items are divided into four domains. The fi rst domain comprises 10 questions addressing physical symptoms and pain. The second domain has four questions and addresses sport, recreation and work. The third is a domain with four questions deal-ing with lifestyle and social functioning. Finally, a fourth domain for emotional well-being with three questions fi nalises the score. The patient is asked to grade the function of each specifi c item on a visual analogue scale from 0 to 100 mm. The total score may be presented as a value between 0 and 2100 points, where 0 represents no defi cit and 2100 the worst defi cit possible. In the present study, we chose to present the results as absolute fi gures of the total score. The WOSI © has been shown to be reliable and has been translated and can therefore be recom-mended when evaluating patients with shoulder instability problems (18).
Shoulder function . Shoulder function was evaluated using the Constant Score (19), which include both subjective evaluations by the patients and physical examination tests. This functional assessment score assess the overall value, or functional state, of a normal, a diseased, or a treated shoulder (20). The subjective assessment consists of 35 points includ-ing pain and activities of daily living (work, recre-ation, sleep and level of use of hands), whereas the remaining 65 points are assigned to the physical examination assessment (AROM and power). The best and total score is 100 points.
Physiotherapy treatment
All the patients were rehabilitated according to the same guidelines by their local physiotherapists. The study comprised 14 local physiotherapists recep-tions in primary healthcare. All shoulders were immobilised for 4 weeks post-operatively in a brace with the arm at the side. During these weeks, minor exercises were instructed for activation of the shoul-der, which aimed to decrease swelling. Free fl exion and internal rotation were allowed from the fi rst post-operative day. After 4 – 5 weeks, the brace was removed and rehabilitation at physiotherapy depart-ments was initiated. The rehabilitation programme consisted of active exercises to regain normal ROM and fl exibility of the shoulder muscle. Free ROM in all directions was permitted. The programme also included dynamic strengthening exercises for the rotator cuff aimed to restore muscle strength and functional capacity. The patient was examined by the surgeon 6 months after the surgery to test shoulder stability and a clinical examinations were performed
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by the physiotherapist as described before. Also, at 6 months, throwing and contact sports were allowed, provided the patients had regained full functional stability in the operated shoulder compared with the normal contralateral shoulder. The rehabilita-tion period varied, as several physiotherapists were included and depending on the interest and compli-ance of the patient. However, the main goal was regaining full functional stability in terms of AROM and strength compared with the contralateral arm (e.g. the ability to perform sport-specifi c skills, bal-listic exercises and overhead activities, as in catch-ing a throwing ball, through a pain free range of motion).
Statistical method
The data are shown separately for each patient group; pre-operative � Group I ( n � 56), 6-month follow-up � Group II ( n � 34) and 7-year follow-up � Group III ( n � 31). Prevalence tables were used to describe categorical data, while means and SD were used to describe continuous data. Wilcoxon ’ s signed-rank test was used to determine signifi cant differ-ences between the injured and non-injured side for the various tests; handgrip strength, isometric shoul-der muscle strength, AROM and Constant Score. The relationships between the muscle strength tests were also investigated using Pearson ’ s correlation coeffi cient, whereas Spearman ’ s correlation coeffi -cient was used to examine the relationships between the muscle strength tests (handgrip strength and isometric shoulder muscle strength) and the Con-stant Score and WOSI © . The level of signifi cance was set at p � 0.05.
Results
Muscle strength measurement
Handgrip strength . Mean ( � SD) values for the maximum voluntary contraction (MVC) handgrip strength measured with the Grippit ® are presented in Table II. There were no signifi cant differences between the injured and non-injured side for men or women in any of the groups ( p � 0.05).
Isometric shoulder muscle strength . Mean ( � SD) values for the isometric shoulder muscle strength in internal rotation, external rotation and elevation measured with the Isobex ® are presented in Table III.
Group I – pre-operative evaluation . Men were signifi -cantly stronger on the non-injured side compared with the injured side in all three directions (internal rotation p � 0.023, external rotation p � 0.016, eleva-tion p � 0.001). No signifi cant differences between the injured and non-injured side were found for women ( p � 0.05).
Group II – 6-month post-operative evaluation . Men were signifi cantly stronger on the non-injured side compared with the injured side in external rotation ( p � 0.001) and elevation ( p � 0.001) strength. There was no signifi cant difference for men in internal rota-tion ( p � 0.139). No signifi cant differences between the injured and non-injured side were found for women ( p � 0.05).
Group III – 7-year post-operative evaluation . There were no signifi cant differences between the injured and non-injured side for men or for women in any of the tested parameters ( p � 0.05).
Range of motion . The mean ( � SD) values for AROM in fl exion, abduction and external rotation in 90 ° abduction are presented in Table IV.
Group I – pre-operative evaluation . For men, there were signifi cant differences between the injured and non-injured side in all the measurements (fl exion p � 0.001, abduction p � 0.005, external rotation in 90 ° abduction p � 0.001). No signifi cant differences between the injured and non-injured side were found for women ( p � 0.05).
Group II – 6-month post-operative evaluation . For men, there were signifi cant differences between the injured and non-injured side in all the measurements in
Table III. Isometric shoulder strength results with mean and standard deviation are given for injured side in Group I (women n � 16, men n � 40), Group II (women n � 3, men n � 31) and Group III (women n � 7, men n � 23).
Group I Group II Group III
Internal rotation women (kg) 6 � 2 8 � 3 7 � 2Internal rotation men (kg) 11 � 3 11 � 2 12 � 3External rotation women (kg) 5 � 2 5 � 1 5 � 1External rotation men (kg) 8 � 2 7 � 2 8 � 2Elevation women (kg) 3 � 1 4 � 1 4 � 1Elevation men (kg) 7 � 3 7 � 3 8 � 3
Table II. Grippit maximum voluntary contraction (MVC) results with mean and standard deviation for injured side are given in Group I (women n � 16, men n � 38), Group II (women n � 3, men n � 31) and Group III (women n � 7, men n � 24).
Group I Group II Group III
MVC women ( n ) 268 � 97 302 � 106 315 � 67MVC men ( n ) 521 � 100 523 � 87 556 � 112
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Clinical evaluation after shoulder surgery 33
favour of the non-injured side (fl exion p � 0.001, abduction p � 0.021, external rotation in 90 ° abduc-tion ( p � 0.001). No signifi cant differences between the injured and non-injured side were found for women ( p � 0.05).
Group III – 7-year post-operative evaluation . Men had a signifi cantly larger AROM on the non-injured side compared with the injured side in fl exion ( p � 0.006) and external rotation in 90 ° abduction ( p � 0.001). There was no signifi cant difference for men in abduc-tion ( p � 0.075). For women, the AROM in external rotation in 90 ° abduction was signifi cantly larger on the non-injured side compared with the injured side ( p � 0.035). No signifi cant differences between the injured and non-injured side were found for women in fl exion and abduction ( p � 0.05).
Health-related quality of life and shoulder function . The median values and ranges for the WOSI © and Constant Score for the injured side are presented in Table V.
Group I – pre-operative evaluation . There were signifi -cant differences in the Constant Score results between the injured and non-injured side for both women ( p � 0.003) and men ( p � 0.001) in favour of the non-injured side.
Group II – 6-month post-operative evaluation . There were signifi cant differences in the Constant Score results between the injured and non-injured side for
men ( p � 0.001), in favour of the non-injured side, whereas there was no side-to-side difference for women ( p � 0.109).
Group III – 7-year post-operative evaluation . The Con-stant Score was signifi cantly higher on the non-injured side for both women ( p � 0.018), and men ( p � 0.042).
Correlations
Group I – pre-operative evaluation . Correlations were found between handgrip strength and shoulder strength in isometric internal rotation ( r � 0.67, p � 0.001), external rotation ( r � 0.69, p � 0.001) and elevation ( r � 0.54, p � 0.001). No correlations were found between the WOSI © and isometric strength in any measurements ( p � 0.05). No correla-tion was found between the WOSI © and handgrip strength ( p � 0.823). A moderate correlation was found between the Constant Score and the WOSI © ( r � 0.46, p � 0.001).
Correlations Group II – 6-month post-operative evalua-tion . Correlations were found between handgrip strength and shoulder strength in isometric internal rotation ( r � 0.40, p � 0.02) and external strength ( r � 0.42, p � 0.01). No correlation was found between handgrip strength and isometric elevation strength ( r � 0.156, p � 0.385). A signifi cant correla-tion was found between the WOSI © and isometric elevation strength ( r � 0.60, p � 0.001). No correla-tion was found between the WOSI © and handgrip
Table IV. Active range of motion (AROM) results with mean and standard deviation are given for injured side and non-injured side in group I (women n � 16, men n � 40), group II (women n � 3, men n � 31) and Group III (women n � 7, men n � 24).
Group I Group II Group III
Injured side Non-injured Injured Non-injured Injured Non-injured
Flexion women ( ° ) 162 � 16 167 � 17 162 � 8 162 � 15 169 � 12 171 � 9Flexion men ( ° ) 157 � 19 173 � 10 159 � 12 170 � 11 162 � 12 168 � 10Abduction women ( ° ) 170 � 25 177 � 8 173 � 12 177 � 6 177 � 5 177 � 5Abduction men ( ° ) 166 � 26 177 � 8 171 � 15 175 � 10 179 � 24 178 � 5External rotation women ( ° ) 95 � 14 103 � 12 90 � 13 100 � 20 89 � 14 101 � 8External rotation men ( ° ) 83 � 21 101 � 12 83 � 15 100 � 15 85 � 12 96 � 14
Table V. Western Ontario Shoulder Instability Index (WOSI) and Constant Score results were median and range are given for injured side in Group I (women n � 14, men n � 40), Group II (women n � 3, men n � 31) and Group III (women n � 7, men n � 23).
Group I Group II Group III
WOSI women (range 2100 – 0) 1006 (63 – 1724) 1032 (644 – 1464) 191 (96 – 509)WOSI men (range 2100 – 0) 1084 (244 – 1885) 568 (76 – 1574) 231 (16 – 1630)Constant Score women (max 100 points) 67 (35 – 87) 68 (66 – 78) 80 (73 – 88)Constant Score men (max 100 points) 72 (31 – 99) 83 (49 – 97) 89 (25 – 99)
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34 S. R. Augustsson et al.
strength ( p � 0.061). A high correlation was found between the Constant Score and the WOSI © ( r � 0.72, p � 0.001).
Correlations Group III – 7-year post-operative evalua-tion . Correlations were found between handgrip strength and shoulder strength in isometric internal rotation ( r � 0.87, p � 0.001), external strength ( r � 0.76, p � 0.001) and elevation strength ( r � 0.77, p � 0.001). No correlations were found between the WOSI © and isometric strength in any direction ( p � 0.05). No correlation was found between the WOSI © and handgrip strength ( p � 0.229). No cor-relation was found between the Constant Score and the WOSI © ( p � 0.099).
Discussion
The results of the present study provide values for several shoulder outcome scores commonly used in clinical assessments and research related to shoulder instability. We believe that, in the fi eld of physiother-apy, a clinical examination pre-operatively and dur-ing the subsequent rehabilitation period including several aspects of shoulder function, is important in order to evaluate the post-operative result and to set realistic goals for the patient. Objective assessments, such as range of motion, muscle strength and level of sporting and occupational activity, registered in a standard evaluation protocol, give both the patient and physiotherapist continuous information about the rehabilitation process. A standard evaluation pro-tocol should also include patients ’ subjective evalua-tions of their shoulder function. In the present study, such standard protocol practised in physiotherapy was used and also scrutinised. For the handgrip strength measurements, there were no signifi cant dif-ferences between the injured and non-injured side for men or women in any of the groups. The values for handgrip strength from all three groups are in accordance with reference values, for the same age group, obtained in a previous study (21). This indi-cates that handgrip strength, according to our study, is not particularly affected after surgical stabilisation of the shoulder. Handgrip strength has previously been shown to correlate to the general isometric muscular strength of the upper extremity (22,23). In the present study, strong correlations were shown in all measurements of isometric shoulder strength in the 7-year post-operative evaluation group (III). However, signifi cant correlations between handgrip and isometric shoulder strength were shown at mod-erate level for the internal and external rotation with the arm at the side and low or no correlations were shown at 90 ° of elevation in the plane of scapula in
Group I and II. It could be argued that the use of the hands at 90 ° is more relevant for this population with shoulder instability, who are often involved in sporting activities, with stress on the shoulder above 90 ° of elevation. Taken together, the handgrip strength merely refl ects muscular isometric shoulder strength, nor being sensitive enough to evaluate muscular strength defi cit, after shoulder stabilisation.
In both Groups I and II, the men were signifi -cantly stronger on the non-injured side compared with the injured side in all measurements of shoulder strength, isometric internal rotation, external rota-tion and elevation strength, whereas no differences between the injured and non-injured side were found for women. There were no signifi cant differences between the injured and non-injured side for either men or women in Group III. Differences between men and women in terms of muscular endurance and strength have been reported in earlier studies (24 – 26). It has been noted that women ’ s (age 19 – 36) upper-body strength and endurance is no more than 44% of men ’ s (age 19 – 36) (22,24,26). One explana-tion for the fact that only the women, and not the men, in the present study were equally strong in the injured side compared with the non-injured side at the 6-month post-operative evaluation could be that women who undergo surgery are more motivated to follow the rehabilitation protocol compared with men. However, because of the restricted sample size of women, it is not possible to determine whether true differences had occurred or whether this was just a random effect. Moreover, when looking at the strength data, comparing the injured side with the non-injured side, it appears that surgery after shoul-der instability does not have an important impact on muscle strength in the upper extremity. In addition, muscle strength has also probably been fully recov-ered 7 years after surgery. Muscle strength may therefore be considered of less importance at the long-term follow-up, as most patients had fully recov-ered at this time. As mentioned in the Method sec-tion, the Isobex ® has shown high reliability (16). However, no evaluation of the validity of the Isobex ® dynamometer has been found in the literature.
When it came to AROM, men had a signifi cantly larger AROM on the non-injured side compared with the injured side in almost every measurement in all groups. As for women, the only detected sig-nifi cance difference was found in external rotation in Group III. Whether men ’ s ROM is more affected by shoulder instability or surgery can only be speculated on. In spite of this, the value for ROM on the injured side appears to be lower, for both women and men, than the reference values obtained in a previous study (27,28). When it comes to AROM, the external rotation in 90 ° abduction may be most affected by
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Clinical evaluation after shoulder surgery 35
surgery after shoulder instability, with a difference equal to 17 ° between the injured and non-injured side for men in Group II. This is not surprising, as one of the goals with Bankart surgery is stabilisation and the ROM consequently deteriorates. With the open Bankart technique, the shoulder loses external rotation, probably because the subscapularis tendon is shortened after the detachment/re-attachment pro-cess (4). The repair of the capsule ligamentous com-plex during shoulder stabilisation procedures has previously been shown to be followed by a persistent limited ability in external rotation (29). Measuring range of motion with a goniometer has shown high reliability (30,31). Also, even if small errors in the con-struction of the goniometer may exist, the handheld goniometer is generally accepted as a valid clinical instrument (31).
There were signifi cant differences in the Con-stant Score results between the injured and non-injured side for women in Groups I and III and for men in all groups. There were no signifi cant differ-ences between the injured and non-injured side for women in group II. Yet, the 6-month post-operative evaluation only consisted of three women. Conse-quently, we do not know if differences would have been noted in this group as well if it had comprised a larger sample size. Normative data for the Constant Score based on age and gender have been presented by Katolik et al. (32) and Constant et al. (19). The values obtained in the present study are lower for Groups I and III compared with the reference values presented by Katolik et al. (32). However, the results in the present study showed that patients ’ Constant Score values 7 years (group III) after surgery were just slightly lower than the normative values obtained by Katolik et al. (32) and correspond well with the values presented by Constant et al. (20). The values from Group III in the present study might therefore be regarded as satisfactory. The WOSI © values obtained in the present study are much lower, for all groups, compared with previously published norma-tive data (33). In our opinion, a large change in score would suggest patient improvement and a meaning-ful clinical change. However, although the scores for the WOSI © in Group III appear to be much lower than for Group I, they are still far from normative values. Only one correlation was found between the WOSI © and muscular strength (isometric elevation strength in Group II), suggesting that muscular strength does not affect the subjective estimation of shoulder condition in these patients. A correlation was found between the WOSI © and the Constant Score in Groups I and II. This is not surprising, as both contain a subjective component. However, when looking at the data, there appear to be greater differences in the WOSI © between Groups I and II
and Group III, whereas the differences seen in the Constant Score between groups were not so large. However, as the groups consisted of different patients, no evaluation in terms of changes over time can be made. To sum up, although the present study has a cross-sectional design, some assumptions can be made when looking at the comparison between the injured and non-injured side. Both the WOSI © and the Constant Score has been shown to be reliable measurements when evaluating patients with shoul-der instability problems (18,19). However, a primary source for validity of the Constant Score has not been found in the literature. Conversely, the WOSI © score has shown good validity and a high degree of responsiveness (18).
According to our observations, there is reason to believe that the rehabilitation programme used in this study is not suffi cient to improve shoulder func-tion as early as 6 months post-operatively. This is somewhat unexpected and might be an important clinical message. As a result, there is clearly a need for a more effective rehabilitation programme, focus-ing on functional rehabilitation rather than mere strength training after stabilising surgery for the shoulder. However, despite being a complex and dif-fi cult task, our ambition should be to develop an effective rehabilitation programme to realise the patient ’ s personal goals, as shown by the WOSI © . The results from the present study can guide the physiotherapist to give patients realistic expectations of shoulder function regarding AROM and muscle strength, which might contribute to higher scores on the WOSI © .
Some limitations in the present study are evident. The relative scarcity of female patients may have affected the analysis and made the fi ndings less appli-cable to women. Power was limited for detecting dif-ferences in the measurements within the groups of women. Twenty patients were included in both Groups I and II, which might also be a weakness, since the study were performed with a cross-sectional design. Moreover, the patients included in the pres-ent study represent a relatively wide range of age. The youngest patient was only 15 years old when he underwent surgery. There could very well be differ-ences in recovery, in muscle strength, ROM and quality of life, between younger and older patients. Also, there might be changes, especially when it comes to muscle strength progress, that emerge from ordinary age-related development, as the study com-prise still growing patients. A total of six women and seven men were under 20 years of age at the time for surgery. Thus, the sample size in the present study is too small to make age-related analyses. In spite of this, we believe that the present study provides an initial insight into and information about shoulder
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36 S. R. Augustsson et al.
function and quality of life after surgical stabilisation of the shoulder. In addition, the proportion of women versus men, as well as the range of age, when it comes to shoulder instability surgery, is in accordance with previous research in the fi eld (34 – 36). Another limi-tation of the present study is that not all the patients were evaluated on all the test occasions (pre-op, 6 months and 7 years). Consequently, no conclusions when it comes to changes over time can be drawn. Another weakness of the present study is that the rehabilitation programme was tailored and therefore not standardised. However, it is our observation that it is commonly appreciated among physiotherapists that many rehabilitation programmes are individual-ised. Furthermore, in the present study at least 14 different physiotherapy departments were involved in the rehabilitation process. It is of interest to fi nd rehabilitation models that can be implemented and take into consideration the individual, both the phys-iotherapist and patient. Starting point, progression and end-points in both injury prevention and in rehabilitation seem to benefi t from being individual-ised (37 – 41). To put it briefl y, the value obtained in the present study provides a typically picture of rehabilitation outcomes after surgery for shoulder instability.
The study was carried out 4 – 7 years ago, 2004 – 2007, and some changes could have been made con-sidering the rehabilitation. Still, according to our clinical experience, the same rehabilitation and eval-uation protocol is still used today. Nevertheless, future research with a larger sample size is still needed to ensure a better understanding of the outcome after shoulder instability surgery. More clinical studies are also needed to test the clinical implications of the present values. From the result of the present study, comparing the injured with the non-injured side, we believe that the Isobex ® dynamometer measuring muscle strength, as well as AROM are important instruments in the evaluation of patients with shoul-der instability surgery. The Isobex ® dynamometer is easy to use and not very expensive and therefore a possible assessment tool at a physiotherapy depart-ment. On the contrary, the Grippit ® that is used to measure handgrip strength could be questioned, since it did not show any differences at all between injured and non-injured side. In addition, in order to capture the patients ’ perception of health WOSI © could be consider as a measurement after shoulder stabilisation surgery.
Conclusions
In conclusion, the present study presents values of different measurements before and after surgery for shoulder instability. Comparing the injured and
non-injured side, AROM appears to be more affected by shoulder instability surgery than muscle strength in the upper extremity. In addition, the patient ’ s sub-jective experience of shoulder instability does not fully refl ect the physical examination. Our data also indi-cate that, after shoulder instability surgery, patients have clearly not recovered 6 months after surgery. The results from the present study can guide the physio-therapist to give patients realistic expectations of shoulder function concerning AROM and muscle strength, following a similar rehabilitation protocol.
Acknowledgements
Financial support was provided by the University of Gothenburg, the V ä stra G ö taland (research and education) Research Fund and the Centre for Sports Medicine Research.
Declaration of interest: The authors report no confl icts of interest. The authors alone are responsible for the content and writing of the paper.
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