Multifactorial Approach Training for Anterior Shoulder Instability in Patients Undergoing Arthroscopic Bankart Repair

Background: Fear for (recurrent) dislocation is a frequently reported patient perception regarding the treatment of anterior shoulder instability and is associated with poor outcomes like decrease in quality of life and unsuccesful return to sport. There is lack of standard multifactorial aftercare of shoulder instability surgery incorporating the psychological component of the experiences trauma of patients with shoulder instability. Therefore, a newly developed Rehabilitation Protocol (REPRO) aims to reduce fear for dislocation in order to increase psychological readiness to return to sport. The aim of this study is to compare the effect on the psychological readiness to return to sport between our new Multifactorial Approach Training (MAT) and Conventional Arthroscopic Bankart Repair Rehabilitation (CABRR) in a single-blinded, multi-center randomized controlled trial.

Methods: Patients, aged 18-67 years, with traumatic anterior shoulder instability, undergoing ABR will be included. Rehabilitation is started within 4 weeks following surgical treatment. Patients will be randomized to either the control group (A) or the MAT group (B). Group A will receive CABRR, according to the American Society of Shoulder and Elbow Therapists (ASSET) guidelines. Group B will receive MAT, following the REPRO. A total of 92 patients will be included, with 46 patients per study arm. Patients will be followed-up for 52 weeks. The primary outcome is change from baseline (surgical intervention; ABR) in Shoulder Instability Return to Sport Index (SIRSI) at 26 weeks postoperatively. Secondary outcomes include Oxford Shoulder Instability Score (OSIS), Subjective Shoulder Value (SSV), fear for dislocation measured with a Numeric Rating Scale (NRS), Tampa Scale of Kinesiophobia in patients with Shoulder Instability (TSK-SI), World Health Organization Quality of Life Questionnaire - BREF (WHOQoL-BREF), Return To Work (RTW), Return To Sports (RTS), shoulder pain measured with a NRS, , number of physiotherapy and outpatient clinic visits and patient satisfaction (VAS). At baseline and at 26 weeks postoperatively patients will undergo a task-based brain activity analysis using functional Magnetic Resonance Imaging (fMRI) to determine functional cerebral changes after treatment. The MATASI trial is to be conducted between 2024 and 2026.

Inclusion criteria

• Primary or recurrent traumatic anterior shoulder dislocation (MRI-confirmed labral tear)
• Aged between 18-67 years
• Planned arthroscopic Bankart repair (ABR) surgery
• Understanding of spoken and written Dutch language
• Written informed consent (according to the ICH-GCP guidelines)
• Positive apprehension sign at physical examination

Exclusion criteria

• Posterior or multidirectional shoulder instability
• Presence of hyperlaxity of the upper extremity and absence of sulcus sign and >85 degrees of external rotation with the arm at the side at physical examination
• Connective tissue disorders (e.g. Ehlers-Danlos)
• Aged <18 or >67 years
• Assymetry in rotator cuff strength, bilateral component ((sub)luxations on contralateral side)
• History of soft tissue repair or bone block procedure on one of both shoulders
• Current or past anxiety disorders or use of anxiety supressing drugs (e.g. anti-psychotics)
• Implantable cardioverter defibrillator (ICD) (unable to be included for functional MRI)
• Neurological disorders or systemic disease
• Loss of anteroinferior sclerotic contour of the glenoid on AP view of the shoulder
• Hill-Sachs lesion visible on external rotation radiographs
• Greater tubercle fracture