€¦ · Web viewAppendix A. Search Strategy for Ovid Medline. Pathology Terms. 1. Joint...

The Efficacy of Exercise for MDI

Appendix A

Search Strategy for Ovid Medline

Pathology Terms

1. Joint Instability/ or Multidirectional Instability.mp.2. joint instability.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]3. unstab*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]4. Atraumatic Instability.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]5. joint laxity.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]6. hypermob*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]7. recurr* sublux*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]8. joint hyperextensib*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]9. Shoulder Dislocation/10. dislocat*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]11. hyperlaxity.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]12. congenital instability.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]13. loose shoulder joint syndrome.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]14. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13

Anatomic Region Terms

15. Shoulder Joint/ or Shoulder/16. shoulder.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]

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17. glenohumeral.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]18. 15 or 16 or 17

Intervention Terms

19. Exercise Movement Techniques/ or Exercise/ or Exercise Therapy/ or exercise.mp.20. Rehabilitation/21. rehabil*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]22. Physical Therapy Modalities/ or physical therapy.mp. or Physical Therapy Specialty/23. non-operative.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]24. Resistance Training/25. strength.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]26. gym.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]27. physiotherapy.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]28. resistance.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]29. conservative.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]30. treat*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]31. kinesiotherapy.mp.32. muscle train*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier]33. 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 3234. 14 and 18 and 3

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Appendix B

Guidelines for the Application of the Tool for Quality Assessment of Studies.

External Validity

Representative: Studies received a if all of the participants in a group had clinically

diagnosed MDI (as outlined in the inclusion criteria of this review) or if the outcomes

and data of participants with clinically diagnosed MDI were reported and analyzed

separately.

Participation Rate: Studies received a if participation rate for the exercise based

group was reported and was 80% or more. Studies received a if participation rate

was below 80% or if participation rate was not reported at all.

Were outcome measures clinically relevantU Studies received a if the outcome tool

could be applied in the majority of clinical settings and administered by a trained

physiotherapist, medical doctor or surgeon.

Internal Validity

Performance.

Exercise intervention observed by expertU Studies received a if the exercise based

management was supervised by a physiotherapist, medical doctor or surgeon.

If more than one therapist is administering the intervention; has an attempt been

made to standardize the interventionU Studies received a if they outlined

standardized instructions that were given to patients on exercises (including dosage,

frequency and duration) or the exercises were clearly outlined in the study for the

reviewer. Studies received a U if it was unknown if more than one therapist was

administering the intervention or if it was unknown if the intervention was

standardized.

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Detection.

Were outcomes measured in the study sensitive enough and/or responsive enough to

measure clinical changes in this populationU

Sensitivity to change refers to the capacity of instruments to measure change

statistically. Responsiveness addresses the detection of clinically relevant change 7.

Studies were given a if they used at least one of the following outcome measures;

the Melbourne Instability Shoulder Score (MISS), the Western Ontario

Shoulder Instability Index (WOSI), the Oxford Instability Score (OIS)

or the Shoulder Rating Questionnaire (SRQ). These outcome

measures have been shown to be reliable and responsive to change

in the shoulder instability population 22.

Studies received a U if they used any of the following outcome measures: the

American Shoulder and Elbow Surgeons score (ASES), the Athletic

Shoulder Outcome Rating Scale (ASORS) and the Simple Shoulder

Test (SST), as they may be moderately responsive for patients with

shoulder instability 22. Studies received a if they used the Row

Score, Modified Rowe Score, Shoulder Rating Questionnaire,

Disabilities of the Shoulder and Hand (DASH) score, and the

University of California, Los Angeles (UCLA) score, as these scales

have either been found to be minimally responsive for patients with

shoulder instability or their development and testing has not been

evaluated 22. Studies received a if they used a dynamometer as this has

been shown to be sensitive enough to measure changes in muscle strength 5 or used

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other measurement tools that the reviewers deem not susceptible to a high level of

measurement bias ( e.g.: computed aided software and electrodes to measure muscle

contraction). Studies also received a U If other scales were used that

have not been shown to be sensitive or responsive for patients with

shoulder instability in the literature.

Adequate time to follow upU Studies were given a if time to follow up was at least 4

weeks as short term studies have shown that most strength gains occur in the first 4-8

weeks of training 18.

Attrition.

Completeness: Studies were given a if the percentage in the final analysis was 80%

or more, or a full description of those lost to follow up was not suggestive of bias.

Selection Bias/Confounding.

Balance between groups if more than oneU If studies compared 2 or more groups

with the same intervention, studies were given a if the groups were similar in

patient characteristics (e.g.: both groups MDI without a history of trauma).

Adjust for confounder in statistical analysisU Studies were given a if they adjusted

their statistical analysis based on components that may have confounded their results

such as patients with a history of trauma, or prior surgery or drop outs.

Reporting.

Were testing procedures for diagnosis clearly defined so that it could be reproducedU

Studies received a if the authors reported the name of the diagnosis tools and how

they were carried out (e.g. position of the patient), and a U if the only the names of the

tests were mentioned.

Intervention clearly outlinedU Studies received a if a description of the duration of

the program (in weeks or months), the dosage (sets and reps) and an explanation of

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the types of exercises were given. Studies received a U if two of the prescription

parameters above were mentioned. Studies were given a . if one or none of the

prescription parameters above were mentioned.

Reliability and validity of diagnostic measures/outcome measures reportedU Studies

received a if they reported the validity and/or reliability of their diagnostic tools

and outcome measures used, and were given a if this was not reported.

Is the size of the effect clinically importantU Studies received a if the effect size

was 0.5 and above. A value of 0.5 is interpreted as a medium clinical effect by

Cohen’s d6.

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Appendix C

The GRADE Approach

Categories of the quality of evidence

High: There is high confidence that the true effect lies close to that of the estimate of

the effect.

Moderate: There is moderate confidence in the effect estimate: the true effect is

likely to be close to the estimate of the effect, but there is a possibility that it is

substantially different.

Low: The panel’s confidence in the effect estimate is limited: the true effect may be

substantially different from the estimate of the effect.

Very Low: There is little confidence in the effect estimate: the true effect is likely to

be substantially different from the estimate of effect.

Definitions and justifications for assessing domains

Study Design: The GRADE’s approach to rating the quality of evidence begins with

the study design and then addresses five reasons to possibly rate down the quality of

evidence and three to possibly rate up the quality 11. In relation to the initial quality of

a body of evidence, Randomised Controlled Trials start with a ‘high’ rating and

observational studies with a ‘low’ rating1. In the event that a control or comparison

group is implicit, absent or unclear in a study, the study will start with an initial

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grading of ‘very low’, as the lack of a control group limits our confidence in the effect

of the intervention 1.

Methodological quality limitation refers to the risk of bias of included trials. As

described in the quality assessment (Appendix C), studies were examined on five

types of bases (performance, detection, attrition, selection and reporting). The overall

quality assessment rating for each study, investigating the outcome of interest, was

used to grade this domain. Following GRADE guidelines 8, 12, studies were

downgraded if, collectively for the outcome; there was a very serious risk of bias (-2)

or serious risk of bias (-1).

(0)No serious risk of bias overall = all studies considered low risk of of bias

overall.

(-1)a Serious risk of bias overall = At least one study considered moderate risk

of bias overall (and others were low).

(-2)b Very serious risk of bias overall = At least one study considered high risk

of bias overall (and others were low or moderate).

Consistency refers to the similarity of treatment effect estimates for each outcome

across the trials. Trial results were considered consistent when directions, effect size

and statistical significance were considered similar enough to draw the same

conclusion 21.

Consistency in direction was defined as 75% or more of the included trials showing

either benefit or no benefit, and consistency of effect when 75% or more of the trials

showing a clinically important or unimportant treatment effect based on the minimum

clinically important difference for the outcome measured in the review 13. If studies

were deemed appropriate to combine in a meta analyses, prior to meta-analysis,

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clinically homogenous trials were first assessed for statistical heterogeneity and in this

situation consistency was defined as absence of statistical heterogeneity ( p>0.1, I2

less than 30 %)11, 19.

The authors hypothesised that due to the poor quality of some included trials, CI’s and

effect sizes may not be available, and therefore the ability to calculate the statistical

variation across studies (I2) would not be possible. In this case, judgments on

consistency across different data sets, and thus treatment effects cannot be made, and

therefore the domain was deemed not applicable.

The criteria for downgrading in the presence and absence of available data are

outlined below:

(0) Direction, clinical effect and I2 all reveal the absence of clinical

heterogeneity.

(-1)c In the case that CI’s were available: A quality point was deducted for

statistically heterogeneity 2. In the case of clinically heterogeneous trials a

quality point was deducted for inconsistent or conflicting (or varying) results 2.

(N/A)#- The domain was considered not applicable if there was only one trial

intervention per outcome 8.

(N/A)+-The domain was not considered applicable if the majority of trials

could not provide data to calculate CI’s and thus between group or within

group treatment effects.

(N/A)^ - The domain was considered not applicable if statistical variation

across studies (I2) was unable to be calculated (despite consistent direction of

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recommendations and clinical effect) therefore judgements on consistency

across different data sets, and thus treatment effects cannot be made.

Directness refers to the extent to which the people, interventions and outcome

measures are similar to those of interest 19, 21. GRADE distinguishes two types of

indirectness. Firstly, indirectness may be due to differences in populations,

interventions and outcomes of interest across studies and encompasses the presence of

clinical heterogeneity 3. Secondly, a conceptually different indirectness occurs when

an intervention has not been tested in a head to head comparison 10. The criteria for

deduction of quality points for indirectness are outlined below:

Type 1 Indirectness

(-1)d A Quality point was deducted if the outcome measures investigated was

not patient specific, and was impairment based rather than activity based or

patient focused 10. Impairment measures included items such as strength

measures, EMG measures, kinematic measures and joint sliding mechanics.

Patient focused measures included patient satisfaction scales, return to

work/sport/activity scales, Constant and Rowe scales and pain scales.

(-1)e A Quality point was deducted if the interventions across studies were

deemed significantly heterogeneous and/or sufficient information was lacking

regarding description of the intervention/s and therefore directness in relation

to intervention could not be assessed. It is rare for interventions to be identical

across studies, and a judgement to deduct a quality point should only be done

if the differences are considered sufficient to make a difference in an outcome

likely 10. However, a quality point will be deducted if the authors deem that

the majority of the intervention/s described could not be implemented with the

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rigor and technical sophistication that the data came from; due to either lack of

information on the intervention characteristics or lack of technical equipment

that would be available in the common rehabilitation setting 10.

Type 2 indirectness

(-1)f A Quality point was deducted if the majority of interventions for that

outcome were not tested against a control or comparison group.

The combined effect of all types of indirectness is not a simple additive process. In

general, evidence based on outcomes that are not of primary interest should usually

trigger rating down, whereas other types of indirectness require a much more

considered judgement 10. Indirectness may be more heavily weighted for one subset

of type 1 directness than for others. Therefore only a total of 1 quality point can be

deduced for type 1 indirectness even if studies reveal indirectness for each of

intervention and non patient focused outcomes. The domain can be downgraded 2

points (-2) if the studies for the outcome of interest are judged as displaying

indirectness for one or more of type 1 indirectness and type 2 indirectness.

Precision refers to the number of trials, participants and the width of the CI for each

outcome 9. There is no empirical evidence for defining imprecise or sparse data 21.

Therefore for the purposes of this review the rules for deduction of quality points are

as follows:

(-1)g Only one trial reported an outcome for the chosen comparison regardless

of the sample size or the confidence interval 9.

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(-1)h If studies were combined in a meta-analysis and the confidence interval

is sufficiently wide that the estimate is consistent with conflicting

recommendations or, (-1)i fewer than 75 % of studies present data that can be

included in a meta-analyses 9, or (-1)i the majority of studies could not provide

data to calculate CI’s and effect sizes.

(-2)j if only one trial reported for an outcome of interest and could not provide

data to calculate CI’s and effect sizes.

Publication (reporting) bias as described within the Cochrane Handbook 13 was only

considered present if actual evidence was found 19

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The Efficacy of Exercise for MDIAppendix D

Quality Assessment of Included Studies

Adapted from “ HIV and male circumcision-a systematic review with assessment of quality studies” by Siegfried et al.,23 2005, Lancet Infectious Diseases, p. 168. indicates that the measure was adequately addressed in the study, indicates that the measure was not adequately assessed in the study, U indicates that the measure was partly addressed in the study or we were unable to determine if it was addressed in the study, N/A = Not Applicable in the study.

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Study Tillander et al,24

Kiss et al,16

Illyés et al15,

Kiss et al,17

Ide et al,14

Misamore, et al,20

Burkhead&Rockwood4

External Validity

Representative Participation rate Were outcomes measures used clinically relevantU

Internal Validity

Performance Control or comparison groupU

Blinding/ Attempt for independent assessor

U

Exercise intervention observed by expert

U U U U U UIf more than one therapist is administering the intervention; has an attempt been made to standardize the interventionU

U U U U U U

Detection Baseline Measurement

Post treatment Measurement

Blinding/ Attempt for independent assessor

U U U U

Were outcomes measured in the study sensitive enough or responsive enough to measure clinical changes in the populationU

U

Adequate time to follow up

Attrition Completeness U Selection Bias/ Confounding

Inc/Exc criteria outlined for study’s definition of MDI

U U

Similar group characteristicsU

U No history of surgical managementU

U UExclusion of Hx of TraumaU

U Imaging to exclude structural lesionU

Adjust for confounder in statistical analysesU

U U N/A N/A N/A N/A N/A

Reporting Bias

Aims of the study clearly statedU

Author’s definition of MDI made clearU

U UWere testing procedures for diagnosis clearly defined so that it could be reproducedU

U U U U U

Intervention clearly outlinedU(method and dosage)

U U U

Outcomes clearly describedU

Reliability and validity of diagnostic measures reportedU

Reliability and validity of outcome measures reportedU

Is the size of the effect clinically importantU

N/A N/A N/AAdverse effects reportedU

p value setU

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Appendix E

Results of Included Studies

Study Before intervention After intervention Summary

Tillander et al, 48 No measures Constant score: Median (Range)Ex only: 82 (68 – 98)

No statistical calculations for Constant Score.Unable to determine the effect of exercise alone for Constant Score.

Rowe score: Median (Range)Ex only: 55 (40 – 100)

Unable to determine the effect of exercise alone for Rowe Score

Satisfied/UnsatisfiedEx only: 9/20 satisfied, 11/20 not satisfied

45 % satisfied after exercise

Return to Sport/No return to sportEx only: 7/11 return, 4/11 no return

No statistical calculations for return to sport.64% return to sport after exercise.Overall 44% of exercise group went on to have surgery.

Kiss et al, 32 No measures Subjective Shoulder Rating System (Mean/SD)No Hx. of Surgery + Ex: 79 (14) Unable to determine the effect of exercise alone for Subjective Shoulder Rating System.

Patient Satisfaction:No Hx. Surgery + Ex.Cured / Improved: 38/62Remained the same: 23/62Worse: 1/62

Patient Satisfaction After Ex.

61% Cured/Improved37% Remained the same2% Worse

Rowe score: Mean (SD)No Hx. of Surgery+ Ex: 50 (29)

Unable to determine the effect of exercise alone for the Rowe Score.

Constant:No Hx. Surgery + Ex.38 / 62 –no / mild disability9 / 62 – moderate

Constant Score After Ex.61% no / mild disability15 % moderate disability24% severe or total disability

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15 / 62 – severe or totalMean(SD): 80 (17)

Illyés et al,27 Constant score:Ex only:Male : 92Female: 93

Constant score:Ex only:Male: 95Female: 94

No standard deviations/no statistical analyses in article for Constant Score.

Maximum EMG:Maximum amplitude of normalised EMG was significantly higher in stabilizing muscles (upper trapezius, infraspinatus, posterior deltoid) and significantly lower in prime movers (pectoralis major, middle deltoid, biceps) of MDI patients with all movements when compared to controls with normal shoulders.

(p=0.05)

Maximum EMG:Ex. only.

Short Term Rx:EMG of stabilizing muscles remained significantly higher (for all movements) and EMG of prime movers significantly lower (for pull, punch and elevation) when compared to controls (p<0.05).

Significant difference in biceps EMG only compared to before Rx EMG values of MDI group (p=.05).

Long Term Rx:EMG of stabilizing muscles remained significantly higher (for all movements) and EMG of prime movers significantly lower (for pull, punch and elevation) when compared to controls (p<0.05).Significant difference in most muscles for most movements compared to before Rx MDI, EMG values (p<0.05). In general a significant decrease EMG value for prime movers and significant increase in EMG values for stabilizing muscles.

Ex. only did not restore the normal muscle activity of muscles around the shoulder compared to controls, however long term exercise did significantly increase the maximum EMG amplitude of activity of most muscles compared to before treatment values of the MDI group (p<0.05).

Long term exercise Ex. only increased the activity of stabilizing muscles and reduced the activity of prime movers compared to controls.

Time BroadnessMDI groups:Significantly longer time broadness (on time) of muscles in MDI group compared to control with slow and fast throw (p = 0.008).

Time BroadnessEx only:

Short Term Rx:Time broadness significantly longer compared to control for slow throw. (p=0.03) and fast throw (p=0.01).No statistical significance in time broadness for slow throw (p=0.34) or fast throw (p=0.19) compared to before Rx MDI value.Long Term Rx:Time broadness was similar when compared to control group for Slow throw (p=0.07). Time broadness was significantly longer for fast throw (p=0.01) compared to controls. No statistical significance before and after MDI values for slow throw (p=0.24)

Long term exercise based treatment increases the proprioception of motion as there was no difference for time broadness (on time) between the MDI and control group (p=0.07) for slow throw only.

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and fast throw (p=0.19).Kiss et al, 33 Kinematics:

1. Scapulothoracic Angle (ST)

MDI: 18.32Control: 27.46

Scapulothoracic Angle (ST)

Ex. only: 18.93, 12 weeks, 22.32, 36 wks.

Ex. only: ST remained significantly lower in MDI exercise group compared to controls at short term and long term follow up (p<0.05). ST increased significantly after exercise at long term follow up (p<0.05).

2. Glenohumeral Angle (GH)

MDI: 56.94Control: 48.09All patients with MDI had significant alterations in shoulder kinematics compared to controls. ST lower in MDI group and GH higher in MDI group compared to controls before treatment. (p<0.05).

Glenohumeral Angle (GH)

Ex. only: 57.08, 12 weeks, 46.03, 36 weeksEx. Only: GH remained significantly higher in MDI exercise group compared to controls at short term and long term follow up (p<0.05). GH decreased significantly compared to measures before exercise at long term follow up (p<0.05).

3. Relative DisplacementMDI: 0.227Control: 0.079Significantly larger range of joint sliding of all MDI patients compared to controls (p<0.001).

Relative Displacement

Ex. only: 0.241,12 wks, 0.134, 36 wksEx. only: Mean values of relative displacement centers remained significantly higher after short term and long term Rx compared to controls. Significant decrease observed after LT Rx compared with values before Rx (p<0.05).

Muscle Activity (on/off patterns)Sig. difference in muscle activity of all MDI patients compared to controls (p<0.001).

Muscle ActivityEx. only: Long term Rx significantly changed activity of middle and post deltoid, infraspinatus compared to values before Rx. Significant difference remains with control group at long term follow up (p<0.05).

Ex. Only: Long term Rx significantly changed the duration of certain muscles compared to measures before Rx (p<0.05) but normal muscle activity could not be restored compared to controls (p<0.05).

Ide et al,26 Rowe: mean 51.9 +/- 16.7Fair (59), Poor (14)

Rowe: mean 74.9 +/- 13.7Excellent (12), Good (36), Fair (24), Poor (1)

No significant difference for range of motionSignificantly improved after rehabilitation for; pain, numbness & stability (p<0.001) Overall 62 shoulders (84.9%) total scores improved.

IR mean peak torque1.05 +/- 0.24kg.m

IR mean peak torque : 1.26 +/- 0.27 kg.mIncrease 33.4%

Significant increase after exercise intervention (p<0.05).

ER peak torque1.33 +/- 0.33kg.m

ER peak torque : 1.84 +/- 0.39 kg.mMean gain: 23.4%

Significant increase after exercise intervention (p<0.05).

ER/IR peak torque ER/IR peak torque Significant decrease after exercise intervention to represent normative values (p<0.05).

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84.7% +/-23.0% 70.5% +/-13.7% (p<0.5)Misamore et al,37 No measures Modified Rowe at 8 years:

5/36 Excellent12/36 Good

No statistics reported in article for Modified Rowe. Overall 47% of patients had a good to excellent result with exercise.

Grading Scale (0-10):

2 years:Pain: 20/39 good-excellentStability: 21/39 good –excellent8 years:Pain: 23/36 good – excellentStability 17/36 good- excellent

No statistics reported in article for Grading Scale.

After Exercise:51% Good- excellent result for pain at 2 years54% Good –excellent result for stability at 2 years63% Good- excellent result for pain at 8 years47% Good –excellent result for stability at 8 years

Limitations (Sport/ADL’s)2 yrs: 12/39 return to sport8 yrs: 7 given up all sports9 lifestyle or employment changes due to instability.

No statistics reported in article for Limitations.At 2 years 31% had given up sportsAt 8 years 41 % had altered ADL’s due to condition.

Overall Status2 years: 28/39 Much better (72%)8 years: 20/36 Much better – better (56%)

At 2 year follow up 66% lost to surgery or had poor or fair outcome. Of those treated with Ex. 72% rated their shoulder as better or much better.At 8 year follow up 70% treated with Surgery or had poor or fair outcome.Of those treated with Ex. 56% rated their shoulder as better or much better.

Burkhead and Rockwood,8

No measures Rowe score:MDI invol.sublux: 29/33 (88%)good/excellent resultsMDI vol. sublux: 6/6 (100%) good/excellent results

No statistical calculations in article.88% MDI with involuntary subluxations and 100% of MDI with voluntary subluxations had good to excellent result after exercise.

Time to become stable: MDI invol.sublux5 weeks (2 – 12)14 weeks (6 – 36) maximum stability

MDI= Multidirectional Instability, Ex=exercise, Rx= treatment, EMG=Electromyographic, Hx = History, ICS=Inferior Capsular Shift, Sublux.=subluxation, Invol.=involuntary, Ant=Anterior, Post=Posterior. Definitions: ST Angle=Scapulothoracic Angle: Angle formed by spatial vectors between the proximal and distal points of the sternum, the acromion and the scapula spine (Angle of movement contributed to elevation by the scapula). GH Angle=Glenohumeral Angle: Angle formed by spatial vectors between the insertion points of the proximal deltoid and the radial lateral epicondyle and the acromion and the scapula spine (Angle of movement contributed to elevation by the glenohumeral joint). Time Broadness: The time elapsed in the percentage of the movement cycle between the peak EMG of the first muscle to reach maximal activity and the peak EMG of the last muscle to reach maximal activity 33. Time broadness describes to what extent the muscles are involved in producing a motion simultaneously during a motion cycle.

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