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Three Part Question

In [adults following surgical repair of Bankart lesions] does [an accelerated compared to a conservative physiotherapy programme] improve [Long term shoulder function & recurrence rate of dislocation]

Clinical Scenario

A fine Irish male professional rugby union player is spear tackled by 2 nasty New Zealand players and sustains a totally undeserved dislocated shoulder. He undergoes operation to reduce the dislocation and repair the associated detached glenoid labrum. The surgeon wants to play safe in the post-operative phase whilst the physios are keen to get him back to playing as soon as possible but are worried about re-dislocation rate and permanent loss of function. Debate ensues about whether an accelerated rehabilitation programme or a more conservative approach should be adopted for him.

Search Strategy

MEDLINE 1966-01/05, CINAHL 1982 –01/05, AMED 1985-01/05, SPORTDiscus 1830-01/05, via the OVID interface, EMBASE 1996-01/05, and the Cochrane database. In addition the PEDro database was searched.
[{(bankart lesion.mp OR labral tear OR glenoid adj5 lesion) AND (exp shoulder OR exp shoulder joint) AND (exp exercise therapy OR exp physical therapy techniques OR physiotherapy.mp OR exp rehabilitation})] PEDro: [ bankart lesion OR labral tear]. LIMIT to human AND English language.

Search Outcome

Only 1 paper was retrieved that was relevant to the 3 part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kim et al 2003 S. Korea	N = 62 post arthroscopic Bankart repair. Group 1:- n=28 immobilisation & conventional rehab. Group 2:- n=34 Accelerated rehab for 3 months inclusion criteria:1.Traumatic unilateral & unidirectional anterior instability 2. Recurrent dislocation 3, not active in sports.# 4. classic Bankart & healthy labrum 5. Bankart lesion ¡Ü 1Cm above midglenoid notch	PRCT	1. Recurrent dislocation rate	1. NSS between Gp2 & Gp1(5.9% v 7.1%)	Results cannot be extrapolated to all instability patients and more serious Bankart lesions. Ill defined long term FU time period. Very specific inclusion criteria: almost best case scenario (see column 2)
			2. Functional shoulder scores	2. NSS between groups
			3. Pain scores	3. Gp2 better than Gp 1 @ 6weeks (VAS 0.9 v 1.5) (P=0.013) butNSS @ final FU
			4. ROM	4. NSS deficit between groups
			5. Mean time to 90% final ERot	5.Gp 2 better than Gp1 (6.9 v 8.9 wks, p<0.001)
			6. Mean % activity return	6. NSS between groups
			7. Mean time to 90% activity return	7. Gp2 better than Gp1 (P <0 .001)
			8. Patient satisfaction with early motion @ final FU	8. Gp 2 better than Gp1 (P <0.001)(satisfactory 68% v 7%. Unsatisfactory 9% v 64%)

Comment(s)

There seem to be some short term benefits from the accelerated rehab programme, notably the pain score at 6 weeks post op, the mean time taken to achieve 90% of gleno-humeral external rotation and 90% of return to activity. 64% of the immobilisation group thought the initial rehab phase was unsatisfactory compared to 9% of the accelerated group.

Clinical Bottom Line

Accelerated rehabilitation in selected patients after Bankarts repair does NOT increase the rate of recurrent dislocation and has the same long term shoulder functional improvement as a prolonged sling immobilisation programme.

References

1. Kim, SH, Ha KI, Jung MW, Lim MS, Kim YM, Park JH. Accelerated rehabilitation after arthroscopic Bankart repair for selected cases: A prospective randomized clinical study. Arthroscopy (2003); 19(7): 722-731