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Introduction: Patients with generalised joint hypermobility, including knee hypermobility (GJHk), often experience knee pain and are typically managed with low-intensity strength training and/or proprioceptive training as part of standard care. However, not all patients experience satisfactory outcomes. High-load strength training may offer additional benefits, such as increased muscle cross-sectional area, neural drive and tendon stiffness, which may reduce pain and improve active knee joint stability during movement tasks and daily activities. So far, no randomised controlled trials (RCTs) have compared high-load strength training with traditional treatment strategies (standard care) for this patient group., Methods and Analysis: In this RCT, we aim to recruit patients with GJHk and knee pain from primary care physiotherapy clinics in the Region of Southern Denmark and via social media. Patients with competing injuries or experience with high-load strength training will be excluded. Patients will be randomised (1:1 ratio) to either 2 weekly sessions of high-load strength training or standard care for 12 weeks. The primary outcome is self-reported knee pain during an activity nominated by the patient as the most aggravating for their present knee pain measured using the Visual Analogue Scale for Nominated Activity (VAS NA , 0-100; 0=no pain and 100=worst imaginable pain). This will be collected at baseline, 6 weeks, 12 weeks and 12 months. Secondary outcomes include self-reported knee function and adverse events (collected at baseline, 12 weeks and 12 months), objective measurements including a 5-repetition maximum single-leg press, proprioception and single-leg-hop for distance (collected at baseline and 12 weeks), and a range of other outcome measures such as fear of movement, tendon stiffness and global perceived effect. We aim to recruit 90 patients in total to detect a 10 mm group difference in the primary outcome with 80% power., Ethics and Dissemination: This study was funded by Independent Research Fund Denmark (grant number 2034-00088B) on 14 June 2022; the Regional Committees on Health Research Ethics for Southern Denmark approved it (S-20230050) on 30 August 2023. The first recruitment site opened on 15 February 2024, and the final results will be submitted to a peer-reviewed journal to inform rehabilitation strategies for symptomatic GJHk.Protocol version 1, dated 4 July 2024., Trial Registration Number: NCT06277401., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Shoulder injuries are a common problem in handball. One likely cause of such injuries is excessive throwing. However, it is difficult to measure the number of player throws in large cohort studies using existing methods accurately. Therefore, the purpose of this study is to develop and validate a method for identifying overhead throws using a low-cost inertial measurement unit (IMU) worn on the wrist. In a two-stage approach, we developed a threshold-based automatic identification method for overhead throws in a laboratory study using the IMU. Subsequently, we validated the suggested thresholds in a field setting by comparing throws identified by the threshold-method to throws identified by video recordings of handball practices. The best set of threshold values resulted in a per-player median sensitivity of 100% (range: 84-100%) and a median positive predictive value (PPV) of 96% (range: 86-100%) in the development study. In the validation study, the per-player median sensitivity dropped to 78% sensitivity (range: 52-91%), while the per-player median PPV dropped to 79% (range: 47-90%). The proposed method is a promising method for automatically identifying handball throws in a cheap and feasible way.

Objective: To synthesize the evidence on conservative interventions for shoulder symptoms in hypermobile Ehlers-Danlos Syndrome (hEDS) and hypermobility spectrum disorder (HSD)., Data Sources: A literature search was conducted using data sources Medline, PEDro, CINAHL, AMED, Elsevier Scopus, and the Cochrane Library from January 1998 to June 2023., Study Selection: The review included primary empirical research on adults diagnosed with hEDS or HSD who experienced pain and/or mechanical shoulder symptoms and underwent conservative interventions. Initially, 17,565 studies were identified, which decreased to 9668 after duplicate removal. After title and abstract screening by 2 independent authors, 9630 studies were excluded. The full texts of the remaining 38 were assessed and 34 were excluded, leaving 4 articles for examination., Data Extraction: Two authors independently extracted data using a predefined extraction table. Quality assessment used the Joanna Briggs Institute checklists and the Template for Intervention Description and Replication., Data Synthesis: The review covered 4 studies with a total of 7 conservative interventions, including exercise programs, kinesiology taping, and elasticized compression orthoses. Standardized mean differences were calculated to determine intervention effects over time. The duration of interventions ranged from 48 hours to 24 weeks, showing positive effect sizes over time in the Western Ontario Shoulder Instability Index, pain levels, improved function in activities of daily living, and isometric and isokinetic strength. Small to negligible effect sizes were found for kinesiophobia during completion of exercise programs., Conclusions: Shoulder symptoms in hEDS/HSD are common, yet significant gaps in knowledge remain regarding conservative interventions, preventing optimal evidence-based application for clinicians. Further research is necessary to explore the most effective intervention types, frequencies, dosages, and delivery methods tailored to the specific requirements of this patient population., (© 2024 The Authors.)

Objectives: To investigate the long-term effectiveness of high-load versus low-load strengthening exercise on self-reported function in patients with hypermobility spectrum disorder (HSD) and shoulder symptoms., Methods: A secondary analysis of a superiority, parallel-group, randomised trial (balanced block randomisation 1:1, electronic concealment) including adult patients (n=100) from primary care with HSD and shoulder pain and/or instability ≥3 months. Patients received 16 weeks of shoulder exercises (three sessions/week): HEAVY (n=50, full-range, high-load, supervised twice/week) or LIGHT (n=50, neutral/mid-range, low-load, supervised three times in total). The 1-year between-group difference in change in self-reported function was measured using the Western Ontario Shoulder Instability Index (WOSI, scale 0-2100, 0=best). Secondary outcomes were self-reported measures including changes in shoulder-related symptoms, function, emotions and lifestyle, quality of life, patient-perceived effect, treatment utility and adverse events. A blinded analyst conducted the analyses using linear mixed model repeated measurements analysis., Results: One-year data were available in 86 out of 100 participants (79% women, mean age 37.8 years) (LIGHT 84%, HEAVY 88%). The mean WOSI score between-group difference favoured HEAVY (-92.9, 95% CI -257.4 to 71.5, p=0.268) but was not statistically significant. The secondary outcomes were mostly inconclusive, but patients in HEAVY had larger improvement in the WOSI emotions subdomain (-36.3; 95% CI -65.4 to -7.3, p=0.014). Patient-perceived effect favoured HEAVY anchored in WOSI-emotions (55% vs 31%, p=0.027) and WOSI-lifestyle (50% vs 29%, p=0.042)., Conclusion: High-load shoulder strengthening exercise was not superior to low-load strengthening exercise in improving self-reported function at 1 year. High-load strengthening exercise may be more effective in improving patient emotions about shoulder pain and function, but more robust data are needed to support these findings., Trial Registration Number: NCT03869307., Competing Interests: Competing interests: STS is associate editor of Journal of Orthopaedic & Sports Physical Therapy, reports personal fees from Munksgaard, Nestlé Health Science and TrustMe-Ed, outside the submitted work, and being a co-founder of Good Life with osteoArthritis in Denmark (GLA:D). GLA:D is a non-profit initiative hosted at the University of Southern Denmark aimed at implementing clinical guidelines for osteoarthritis in clinical practice. JS reports receiving grants from Astra-Zeneca, outside the submitted work., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To describe 1-week and 1-year prevalence of spinal pain and its consequences in relation to leisure activity, work-life, and care-seeking in people with type 1 and 2 diabetes mellitus (DM)., Methods: A cross-sectional survey including adults diagnosed with DM from two Danish secondary care centres. Using the Standardised Nordic Questionnaire, spinal pain prevalence (cervical, thoracic, lumbar) and its consequences were evaluated (proportions, 95% confidence intervals) and compared to the general population., Results: Among 3767 people, 1-week and 1-year spinal pain prevalence were 11.6-32.4 and 18.5-49.6%, respectively, highest for lumbar pain (24.6-49.6%). The prevalence was similar between DM types for cervical and thoracic pain, but higher in type 2 for lumbar spine. Women had higher pain prevalence across spinal regions and DM types, while cervical and thoracic pain estimates were higher for age < 60 vs. ≥ 60. Within the past year, > 50% reported pain > 30 days, high proportions had reduced their activities (leisure time, 43.7-63.9%; work, 20.7-33.3%), 13.3-28.1% reported sick-leave > 30 days, and 44.3-48.5% had sought care due to spinal pain., Conclusion: Spinal pain is common in people with type 1 and 2 DM, resulting in considerable consequences for work/leisure activities, sick-leave, and healthcare utilisation as compared to the general population., (© 2023. The Author(s).)

Background: Shoulder symptoms are common in patients with hypermobility spectrum disorders (HSD), but few studies focus on identifying factors associated with treatment effects., Aim: To identify baseline and clinical characteristics associated with a better outcome 16 weeks after starting an exercise-based treatment in patients with HSD and shoulder symptoms., Design: Exploratory secondary analysis of data from a randomised controlled trial., Method: Self-reported treatment outcome was reported as change between baseline and follow-up after 16 weeks of high-load or low-load shoulder strengthening. Multiple linear and logistic regressions were used to investigate associations of patient expectations of treatment effect, self-efficacy, fear of movement, and symptom duration with change in shoulder function, shoulder pain, quality of life, and patient reported health change. All regression models were performed firstly with adjustments for covariates (age, sex, body mass index, hand dominance, treatment group, and baseline score of the outcome variable) and secondly with additional adjustments for exposure variables., Results: Expectations of complete recovery were associated with an increased odds of perceiving an important improvement in physical symptoms after a 16-week exercise-based treatment program. Higher self-efficacy at baseline seemed to be associated with improved shoulder function, shoulder pain and quality of life. A higher fear of movement seemed to be associated with increased shoulder pain and decreased quality of life. A longer symptom duration was associated with decreased quality of life., Conclusion: Expectations of complete recovery, higher self-efficacy, lower fear of movement and shorter symptom duration seem to be important for better treatment outcomes., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Digital health interventions for managing chronic conditions have great potential. However, the benefits and harms are still unclear., Objective: This systematic review and meta-analysis aimed to investigate the benefits and harms of digital health interventions in promoting physical activity in people with chronic conditions., Methods: We searched the MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases from inception to October 2022. Eligible randomized controlled trials were included if they used a digital component in physical activity promotion in adults with ≥1 of the following conditions: depression or anxiety, ischemic heart disease or heart failure, chronic obstructive pulmonary disease, knee or hip osteoarthritis, hypertension, or type 2 diabetes. The primary outcomes were objectively measured physical activity and physical function (eg, walk or step tests). We used a random effects model (restricted maximum likelihood) for meta-analyses and meta-regression analyses to assess the impact of study-level covariates. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation., Results: Of 14,078 hits, 130 randomized controlled trials were included. Compared with usual care or minimal intervention, digital health interventions increased objectively measured physical activity (end of intervention: standardized mean difference [SMD] 0.29, 95% CI 0.21-0.37; follow-up: SMD 0.17, 95% CI 0.04-0.31) and physical function (end of intervention: SMD 0.36, 95% CI 0.12-0.59; follow-up: SMD 0.29, 95% CI 0.01-0.57). The secondary outcomes also favored the digital health interventions for subjectively measured physical activity and physical function, depression, anxiety, and health-related quality of life at the end of the intervention but only subjectively measured physical activity at follow-up. The risk of nonserious adverse events, but not serious adverse events, was higher in the digital health interventions at the end of the intervention, but no difference was seen at follow-up., Conclusions: Digital health interventions improved physical activity and physical function across various chronic conditions. Effects on depression, anxiety, and health-related quality of life were only observed at the end of the intervention. The risk of nonserious adverse events is present during the intervention, which should be addressed. Future studies should focus on better reporting, comparing the effects of different digital health solutions, and investigating how intervention effects are sustained beyond the end of the intervention., Trial Registration: PROSPERO CRD42020189028; https://www.crd.york.ac.uk/prospero/display&#95;record.php?RecordID=189028., (©Graziella Zangger, Alessio Bricca, Behnam Liaghat, Carsten B Juhl, Sofie Rath Mortensen, Rune Martens Andersen, Camma Damsted, Trine Grønbek Hamborg, Mathias Ried-Larsen, Lars Hermann Tang, Lau Caspar Thygesen, Søren T Skou. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 06.07.2023.)

Aims: To describe the one-week and 12-month prevalence of musculoskeletal pain in the upper and lower extremities and consequences in relation to care seeking, leisure time activity, and work life in patients with type 1 and 2 diabetes., Methods: A cross-sectional survey including adults diagnosed with type 1 and 2 diabetes from two Danish secondary care databases. Questions covered pain prevalence (shoulder, elbow, hand, hip, knee, ankle) and its consequences based on the Standardised Nordic Questionnaire. Data was presented using proportions (95 % confidence intervals)., Results: The analysis included 3767 patients. The one-week prevalence was 9.3-30.8 % and 12-month prevalence 13.9-41.8 %, highest for shoulder pain (30.8-41.8 %). The prevalence was similar between type 1 and 2 diabetes for the upper extremity, but higher in type 2 for the lower extremity. Women had a higher pain prevalence for any joint for both diabetes types, while estimates did not vary between age groups (<60 or ≥60 years). More than half of the patients had reduced their activities at work or leisure time, and more than one-third had sought care during the past year because of pain., Conclusions: Musculoskeletal pain in the upper and lower extremities is common in patients with type 1 and 2 diabetes from Denmark, with considerable consequences for work and leisure activities., Competing Interests: Competing interest The authors declare no conflicts of interest related to this work., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

This statement paper summarises and appraises the evidence on diagnosis, prevention, and treatment of common shoulder injuries in sports. We systematically searched Medline and Embase. The Grading of Recommendations Assessment, Development and Evaluation tool was applied to evaluate the overall quality of evidence.For diagnosis, we included 19 clinical tests from mixed populations. Tests for anterior instability, biceps-labrum complex injuries and full subscapularis rupture had high diagnostic accuracy (low to moderate quality of evidence).For prevention, the Oslo Sports Trauma Research Center, the Shoulder Control, the FIFA 11+ shoulder injury prevention programmes, and a baseball-specific programme (range of motion, stretching, dynamic stability and strengthening exercises) showed moderate to large effect size in reducing the risk of shoulder injury compared with no intervention (very low to moderate quality of evidence).For treatment, a rehabilitation programme including stretching, ice packs, electrotherapy and compression, and strengthening exercises showed a large effect size in reducing pain and disability compared with no intervention in athletes with subacromial impingement syndrome (very low to moderate quality of evidence). For the treatment of supraspinatus tendinopathy, hyperthermia treatment (heating the skin to 38°C-40°C) resulted in large effect size in reducing pain and disability compared with ultrasound or pendular swinging and stretching exercises (moderate quality of evidence). Strengthening exercise alone or in combination with stretching exercises promoted a large effect in reducing shoulder pain (cohort studies, no comparators) (very low quality of evidence). The quality of evidence for most estimates was low to moderate, indicating that future high-quality research may alter our recommendations for clinical practice., Competing Interests: Competing interests: KT is Deputy Editor in BJSM. KT and JRP have received grants from the Danish Society of Sports Physical Therapy unrelated to the present study., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Patients with hypermobility spectrum disorder (HSD) and shoulder complaints may suffer from symptoms related to shoulder instability, laxity, and hypermobility. It is currently unknown whether having a more complex clinical status with several diagnoses (i.e., anterior instability (AI), multidirectional instability (MDI), and/or symptomatic localised shoulder hypermobility (LSH), relates to higher functional impairments and pain., Objectives: To investigate the associations between either ≤1, 2, or 3 clinical shoulder diagnoses (AI, MDI, and LSH) or the number (0-10) of positive clinical shoulder tests with shoulder function using the western Ontario shoulder instability index (WOSI, 0-2100, 0 = best) and pain intensity using numerical pain rating scale (NPRS, 0-10, 10 = worse)., Design: Exploratory cross-sectional study., Method: From a randomised controlled trial, baseline data from 100 participants with HSD and shoulder complaints for at least three months were included. Associations were investigated using linear regression models, adjusted for age, sex, body mass index, and hand dominance., Results: Compared with having ≤1 diagnosis, neither participants with two (WOSI 76.9, 95% CI -136.3, 290.0; NPRS 0.3, 95% CI -0.9, 1.5) nor three (WOSI 35.5, 95% CI -178.5, 249.6; NPRS 0.1, 95% CI -1.1, 1.3) clinical shoulder diagnoses had significantly worse shoulder function or pain. Likewise, the number of positive clinical shoulder tests was not associated with function (WOSI -20.8 95%CI (-55.3, 13.7)) or pain (NPRS -0.1 95%CI (-0.2, 0.1))., Conclusions: In participants with HSD and shoulder complaints, having more additional shoulder diagnoses or increased number of positive shoulder tests were not related to functional impairments or pain intensities., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: An increasing number of patients with displaced proximal humerus fractures (PHF) are being offered non-surgical treatment, including short immobilisation and structured rehabilitation. There are no randomised controlled trials (RCTs) comparing structured rehabilitation with non-structured rehabilitation to investigate the benefits of structured rehabilitation., Methods and Analysis: In this RCT, patients with a displaced PHF will be assessed for eligibility at a Danish university outpatient clinic. Patients with competing injuries or patients offered surgery will be excluded, and randomisation will be 1:1. All patients will receive standard orthopaedic follow-up, including 14-day postinjury immobilisation, and advice about returning to activities of daily living before being allocated to structured rehabilitation in the municipalities or non-structured rehabilitation. The primary outcome is the between-group difference in the Oxford Shoulder Score (0-48 points, 48=best, minimal clinically important difference=10) at 6 months. A sample size of 60 patients will allow us to show a 10-point difference with 80% power., Ethics and Dissemination: Funded by Department of Orthopaedics, Zealand University Hospital (grant number N/A) and Region Zealand Health Science Research Foundation (R32-A1108-B14), 14 January 2022; The Ethics committee in Region Zealand approved (EMN-2022-02449), 8 April 2022. The site opened on 5 May 2022, and the final results will be updated on trial registries, submitted to a peer-reviewed journal, and inform rehabilitation strategies after displaced PHFs. Protocol version 1, 21 April 2022., Trial Registration Number: NCT05302089., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe the clinical characteristics of patients with hypermobility spectrum disorders (HSD) and shoulder complaints with or without mechanical symptoms, and to compare characteristics between these groups., Design: A cross-sectional study., Setting: Primary care., Participants: One-hundred patients with HSD and shoulder complaints for at least 3 months were included from primary care (N=100)., Interventions: Not applicable., Main Outcome Measures: Medical history, self-reported (shoulder pain and function, discomfort due to other symptoms, fatigue, fear of movement, quality of life) and objective (strength, range of motion, proprioception) characteristics were collected by physiotherapists. Mechanical symptoms (yes/no) were defined as self-reported shoulder instability, subluxation, and/or laxity., Results: Sixty-seven reported mechanical symptoms. Patients in both groups reported impairments related to shoulder pain, function, fatigue, fear of movement, and quality of life. Patients with mechanical symptoms were younger (mean, 35.1 years [95% CI, 32.3-37.9 years] vs 43.3 years [95% CI, 38.4-48.1 years]), had longer symptom duration (median, 46 months [95% CI, 36-66 months] vs 24 months [95% CI, 9-56 months]), reported a previous shoulder dislocation (25% [95% CI, 16-37] vs 3% [95% CI, 0-16]), experienced that their shoulder was loose (64% [95% CI, 52-76] vs 15% [95% CI, 5-32]), and reported discomfort due to other symptoms (odds ratio, 1.48 [95% CI, 1.17-1.87]). Furthermore, a larger proportion had received supplemental treatment (analgesic medication, steroid injection/surgery)., Conclusions: Both groups with HSD and shoulder complaints presented with substantial shoulder-related impairments. Two-thirds reported mechanical symptoms, were younger, and more severely impaired than those without mechanical symptoms. These findings highlight the importance of managing mechanical shoulder symptoms to fully address the patients' impairments., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: To investigate the short-term effectiveness of high-load versus low-load strengthening exercise on self-reported function in patients with hypermobility spectrum disorder (HSD) and shoulder symptoms., Methods: A superiority, parallel-group, randomised trial (balanced block randomisation, electronic concealment) including adult patients (n=100) from primary care with HSD and shoulder pain and/or shoulder instability ≥3 months. Patients received 16 weeks of shoulder exercises (three sessions/week): HEAVY (n=50, full-range, high-load, supervised twice/week) or LIGHT (n=50, neutral/mid-range, low-load, supervised three times). The primary outcome was the 16-week between-group difference in self-reported function measured with the Western Ontario Shoulder Instability Index (WOSI, scale 0-2100, 0=best, minimal important difference 252 points). Secondary outcomes were self-reported measures including quality of life and clinical tests including shoulder muscle strength and range of motion. An intention-to-treat analysis with multiple imputation was conducted by a blinded biostatistician using linear regression., Results: 93 of 100 patients (93%) completed the 16-week evaluation. The mean WOSI score between-group difference significantly favoured HEAVY (-174.5 points, 95% CI -341.4 to -7.7, adjusted for age, sex, baseline score, clustering around clinic). The secondary outcomes were inconclusive, but patients in HEAVY were less likely to have a positive shoulder rotation test >180°, and more likely to rate an important improvement in physical symptoms. There were no serious adverse events, but HEAVY was associated with more transient muscle soreness (56% vs 37%) and headaches (40% vs 20%)., Conclusion: High-load shoulder strengthening exercise was statistically superior to low-load strengthening exercise for self-reported function at 16 weeks and may be used in primary care to treat patients with HSD and shoulder pain and/or instability to improve shoulder function in the short term. Further studies are needed to confirm the clinical relevance, and patients should be supported to manage associated minor adverse events., Trial Registration Number: NCT03869307., Competing Interests: Competing interests: STS reports personal fees from the Journal of Orthopaedic & Sports Physical Therapy, grants from The Lundbeck Foundation, and personal fees from Munksgaard, outside the submitted work, and being a co-founder of Good Life with osteoArthritis in Denmark (GLA:D®). GLA:D is a non-profit initiative hosted at the University of Southern Denmark aimed at implementing clinical guidelines for osteoarthritis in clinical practice. JS reports receiving grants from Astra-Zeneca, outside the submitted work., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To develop a feasible protocol for testing maximum shoulder rotation strength in tetraplegic wheelchair athletes, and investigate concurrent validity of maximum isometric handheld dynamometer (HHD) towards maximum isokinetic dynamometer (ID) strength measurements; secondly, to study shoulder muscle activation during maximum shoulder rotation measurements, and the association between shoulder strength and shoulder pain. Design: Descriptive methodological. Setting: Danish Wheelchair Rugby (WCR) association for WCR tetraplegic athletes from local WCR-clubs. Participants: Twelve adult tetraplegics. Interventions: N/A. Outcome measures: Wheelchair User's Shoulder Pain Index (WUSPI) and Visual Analog Scale (VAS) measured shoulder pain, isometric HHD and ID (60°/s) measured maximum internal (IR) and external (ER) shoulder rotation strength. Surface Electromyography normalized to maximum EMG measured muscle activity (mm Infraspinatus and Latissimus Dorsi) during maximum shoulder rotation strength. Results: Concurrent validity of isometric HHD towards ID showed Concordance Correlation Coefficients of left and right arms 0.90 and 0.86 (IR), and 0.89 and 0.91 (ER), with no difference in muscle activity between isometric HHD and ID, but larger co-activation during ER. There was no association between shoulder strength and pain, except for significantly weak negative associations between ID and pain during ER for left and right arms (P   = 0.03; P   = 0.04). Conclusion: Standardized feasible protocol for tetraplegic wheelchair athletes for measuring maximum shoulder rotation strength was established. Isometric HHD is comparable with ID on normalized peak torques and muscle activity, but with larger co-activation. Strength was not clearly associated with shoulder pain.

Objective: To study the effects of supervised training in adults with subacromial pain syndrome., Data Sources: Embase, MEDLINE, Cochrane Library, Cumulative Index to Nursing and Allied Health, and Physiotherapy Evidence Database were searched from inception to March 2020., Study Selection: Independent reviewers selected randomized controlled trials comparing supervised training with (1) no training or (2) self-training in adults with subacromial pain syndrome lasting for at least 1 month. Critical outcomes were shoulder pain, function, and patient-perceived effect. Important outcomes included other potential benefits and adverse events at 3-month follow-up., Data Extraction: Two independent reviewers extracted data for the meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias tool 1, and certainty of evidence was evaluated using the Grades of Recommendation Assessment, Development, and Evaluation (GRADE)., Data Synthesis: Ten studies (n=597, 43% female) were included. Supervised training resulted in larger improvements than no training on pain (at rest: n=286; mean difference [MD], 1.68; 95% confidence interval [CI], 0.31-3.06 on 0-10 scale; during movement: n=353; MD, 1.84; 95% CI,0.91-2.76), function (n=396; standardized MD, 0.30; 95% CI, 0.07-0.52), and patient-perceived effect (n=118; risk ratio, 1.43; 95% CI, 0.87-2.34). Supervised training had potential benefits regarding quality of life, return to work, dropout, and training adherence, albeit more patients reported mild, transient pain after training. Supervised training and self-training showed equal improvements on pain (n=44) and function (n=76), with no data describing patient-perceived effect. Certainty of evidence was low for critical outcomes and low-moderate for other outcomes., Conclusions: Supervised training might be superior to no training and equally effective as self-training on critical and important outcomes. Based on low-moderate certainty of evidence, these findings support a weak recommendation for supervised training in adults with subacromial pain syndrome., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Joint hypermobility in athletes is associated with increased risk of knee injuries, but its role in relation to shoulder injuries has not been scrutinized. Therefore, our aim was to synthesize the evidence on the association between joint hypermobility and shoulder injuries in athletes., Methods: Data sources were MEDLINE, CINAHL, EMBASE, and SPORTDiscus from inception to 27th February 2021. Eligibility criteria were observational studies of athletes (including military personnel), mean age ≥ 16 years, and with a transparent grouping of those with and without joint hypermobility. A broad definition of joint hypermobility as the exposure was accepted (i.e., generalised joint hypermobility (GJH), shoulder joint hypermobility including joint instability). Shoulder injuries included acute and overuse injuries, and self-reported pain was accepted as a proxy for shoulder injuries. The Odds Ratios (OR) for having shoulder injuries in exposed compared with non-exposed athletes were estimated using a random effects meta-analysis. Subgroup analyses were performed to explore the effect of sex, activity type, sports level, study type, risk of bias, and exposure definition. Risk of bias and the overall quality of evidence were assessed using, respectively, the Newcastle-Ottawa Scale and the Grading of Recommendations Assessment, Development and Evaluation (GRADE)., Results: Among 6207 records, six studies were included with 2335 (range 118-718) participants (34.1% females; athlete mean age 19.9 years). Athletes with joint hypermobility were more likely to have shoulder injuries compared with athletes without joint hypermobility (OR = 3.25, 95% CI 1.64, 6.43, I 2  = 75.3%; p = 0.001). Exposure definition (GJH, OR = 1.97, 95% CI 1.32, 2.94; shoulder joint hypermobility, OR = 8.23, 95% CI 3.63, 18.66; p = 0.002) and risk of bias (low, OR = 5.25, 95% CI 2.56, 10.8; high, OR = 1.6, 95% CI 0.78, 3.29; p = 0.024) had large impacts on estimates, while the remaining subgroup analyses showed no differences. The overall quality of evidence was low., Conclusion: Joint hypermobility in athletes is associated with a threefold higher odds of having shoulder injuries, highlighting the need for prevention strategies in this population. However, due to low quality of evidence, future research will likely change the estimated strength of the association., Protocol Registration: Open Science Framework registration osf.io/3wrn9.

Background: Four out of five patients with hypermobility spectrum disorder (HSD) or hypermobile Ehlers-Danlos syndrome (hEDS) experience shoulder complaints including persistent pain and instability. Evidence suggests that patients with HSD/hEDS who experience knee and back complaints improve with exercise-based therapy. However, no study has focused on exercise-based treatment for the shoulder in this patient group. The potential benefits of strengthening the shoulder muscles, such as increased muscle-tendon stiffness, may be effective for patients with HSD/hEDS who often display decreased strength and increased shoulder laxity/instability. The primary aim is to investigate the short-term effectiveness of a 16-week progressive heavy shoulder strengthening programme and general advice (HEAVY) compared with low-load training and general advice (LIGHT), on self-reported shoulder symptoms, function, and quality of life., Methods: A superiority, parallel group, randomised controlled trial will be conducted with 100 patients from primary care with HSD/hEDS and shoulder complaints (persistent pain and/or instability) for more than 3 months. Participants will be randomised to receive HEAVY (full range of motion, high load) or LIGHT (neutral to midrange of motion, low load) strengthening programme three times weekly with exercises targeting scapular and rotator cuff muscles. HEAVY will be supervised twice weekly, and LIGHT three times during the 16 weeks. The primary outcome will be between-group difference in change from baseline to 16-week follow-up in the Western Ontario Shoulder Instability Index (WOSI, 0-2100 better to worse). Secondary outcomes will include a range of self-reported outcomes covering symptoms, function, and quality of life, besides clinical tests for shoulder strength, laxity/instability, and proprioception. Outcome assessors will be blinded to group allocation. Participants will be kept blind to treatment allocation through minimal information about the intervention content and hypotheses. Primary analyses will be performed by a blinded epidemiologist., Discussion: If effective, the current heavy shoulder strengthening programme will challenge the general understanding of prescribing low-load exercise interventions for patients with HSD/hEDS and provide a new treatment strategy. The study will address an important and severe condition using transparent, detailed, and high-quality methods to potentially support a future implementation., Trial Registration: ClinicalTrials.gov NCT03869307 . Registered on 11 March 2019.

Background: People with hypermobility spectrum disorder (HSD) are in great risk of experiencing shoulder symptoms, but evidence for treatment is sparse. Therefore, the objective was to evaluate the feasibility of 16-week shoulder strengthening programme for improving shoulder strength and function in people with HSD and shoulder symptoms for more than 3 months to inform a future randomised controlled trial (RCT)., Methods: Twelve participants (11 females, 39.3 ± 13.9 years) with HSD and shoulder instability and/or pain for more than 3 months underwent a 16-week heavy shoulder strengthening exercise programme three times weekly using exercises targeting scapular and rotator cuff muscles. Primary outcomes were pre-defined research progression criteria including recruitment rate (acceptable, 6 participants/month), assessment duration (acceptable: < 120 min), participant retention (acceptable: > 80% complete intervention), training adherence (acceptable: > 75% adhere to > 36 training sessions) and adverse events (acceptable: minor events with no participants discontinuing the study), besides participant and physiotherapist feedback. Secondary treatment outcomes were assessed using the Western Ontario Shoulder Instability Index (WOSI, 0-2100 better to worse), self-reported pain, kinesiophobia and fatigue, isometric shoulder strength, besides clinical tests for instability, hypermobility, laxity, and proprioception., Results: Recruitment rate was 5.6/month, assessment duration (mean ± SD) 105 ± 9 min, retention 100%, adherence 83%, and four participants experienced short-lasting soreness or pain. Participant feedback was positive, and physiotherapists found the intervention relevant and applicable to the population. The WOSI total score showed an improvement by 51% (mean ± SD, points: baseline 1037 ± 215; Follow up 509 ± 365; mean change (95% CI), - 528 (- 738, - 318)), and participants reported reduced pain, kinesiophobia and fatigue. Shoulder strength measurements improved by 28-31% (mean change (95% CI), Nm/kg: scaption 0.51 (0.23, 0.78); internal rotation 1.32 (0.70, 1.95) and external rotation 0.89 (0.37, 1.40)), and clinical tests indicated decreased shoulder laxity/instability., Conclusions: The shoulder strengthening exercise programme was feasible and safe for people with HSD and long-lasting shoulder symptoms. A future RCT, with an improved recruitment strategy, will demonstrate whether the exercise programme is also effective in improving symptoms and muscle-tendon function in this population., Trial Registration: ClinicalTrials.gov: NCT03547570. Registered on May 3, 2018., Competing Interests: Competing interestsSTS reports personal fees from the Journal of Orthopaedic & Sports Physical Therapy, grants from The Lundbeck Foundation, personal fees from Munksgaard, outside the submitted work; and being a co-founder of GLA:D. GLA:D is a non-profit initiative hosted at the University of Southern Denmark aimed at implementing clinical guidelines for osteoarthritis in clinical practice. JS reports grants from Astra-zeneca, outside the submitted work. BL, UJ, KS and BJK have nothing to disclose., (© The Author(s) 2020.)

Objective: To investigate change in shoulder rotation strength from preseason to midseason during a competitive season in youth elite handball players without shoulder problems., Design: Prospective cohort study., Methods: Players (n = 292, 45% female, 14-18 years of age) without shoulder problems from Danish youth elite handball clubs were assessed in the preseason and midseason. We measured isometric shoulder strength using handheld dynamometry in internal rotation (IR) and external rotation (ER) in supine, with the shoulder abducted 90° in neutral rotation and in 30° of IR. The primary outcome was the change in corresponding ER/IR ratio., Results: The mean ER/IR ratios increased from preseason to midseason in neutral rotation (male player difference, 0.02; 95% confidence interval [CI]: -0.01, 0.06; female player difference, 0.05; 95% CI: 0.01, 0.09) and in 30° of IR (male player difference, 0.15; 95% CI: 0.11, 0.20; female player difference, 0.12; 95% CI: 0.07, 0.17). The change in ER/IR ratio may be explained by an increase in ER strength in female players and a decrease in IR strength in male players. The amount of change in ER/IR ratio over the season was greater than individual measurement error metrics for 45% to 66% of the players., Conclusion: Shoulder rotation strength ratios changed during a competitive season in Danish youth elite handball players. J Orthop Sports Phys Ther 2020;50(7):381-387. doi:10.2519/jospt.2020.9183 .

Background and aims Traumatic anterior shoulder dislocation (ASD) is frequent in active populations and associated with a 39% higher risk of recurrent dislocation, which may cause persistent shoulder problems, pain, and impaired shoulder-related quality of life. While local and distant pressure pain sensitivity has been demonstrated in other shoulder conditions, little is known about the link between pressure pain sensitivity and ASD. The interesting aspect is whether recurrent dislocation - resulting in symptoms of longer duration - is associated with more pronounced pressure pain sensitivity, or if presence of pressure pain sensitivity may be part of the reasons why patients develop recurrent dislocation. Therefore, this study aimed at evaluating whether patients with recurrent ASD display greater pressure pain sensitivity and more painful body sites than patients with first-time ASD. Methods This was a cross-sectional analysis of baseline data from a randomized controlled trial including 34 patients with first-time ASD [82% male, mean (SD) age 26 (7) years] and 22 patients with recurrent ASD [96% male, mean (SD) age 25 (5) years]. Patients were assessed as follows: (1) assessment of local and distant pressure pain sensitivity evaluated by pressure pain thresholds (PPTs) using a handheld algometer on mm. trapezius superior, levator scapula, pectorales major, deltoideus, and tibialis anterior, (2) pain intensity at rest during the previous 24 h, (3) number of ASD, and (4) number of painful body sites on a region-divided body chart. Results The PPTs were not significantly different between first-time and recurrent ASD [mean (SD) kPa for m. trapezius superior 264 (110) vs. 261 (88), m. levator scapula 301 (157) vs. 325 (163), m. pectorales major 234 (163) vs. 269 (130), m. deltoideus 290 (166) vs. 352 (173), m. tibialis anterior 420 (202) vs. 449 (184)], two-way ANCOVA, adjusted for sex and age, F (4,263) = 0.29, p = 0.88. For both groups, the PPTs were lower at the shoulder sites than at m. tibialis anterior (difference 117-184 kPa, 95% CI range 33-267). Females had lower PPTs than males (difference 124 kPa, 95% CI 64-183). The number (SD) of painful body sites were 2.2 (1.9) for first-time ASD and 2.6 (5.4) for recurrent ASD, with no between-group differences, one-way ANCOVA, adjusted for sex and age, F (1, 52) = 0.24, p = 0.63. There was a strong correlation between PPTs at the shoulder and lower leg, r = 0.84, p < 0.01. Conclusions This study demonstrated no differences in local and distant pressure pain sensitivity or number of painful body sites between patients with first-time and recurrent ASD. Females had lower PPTs than males, and a strong correlation was found between PPTs at the shoulder and lower leg. Implications Patients with first-time and recurrent ASD seem to have similar pressure pain sensitivity, but lower PPTs compared to existing normative data, suggesting that it is relevant to evaluate the status of the pain system in these patients to prevent triggering or worsening of their symptoms. However, it remains unanswered how these changes affect the patients' ability to undergo rehabilitation, symptom response and long-term shoulder function.

Introduction: Shoulder pain is highly prevalent in competitive swimmers, and generalized joint hypermobility (GJH) is considered a risk factor. Sensorimotor control deficiencies and altered neuromuscular activation of the shoulder may represent underlying factors., Research Question: To investigate whether competitive swimmers with GJH including shoulder hypermobility (GJHS) differ in shoulder sensorimotor control and muscle activity from those without GJH and no shoulder hypermobility (NGJH)., Methods: Competitive swimmers (aged 13-17) were recruited. GJHS or NGJH status was determined using the Beighton score (0-9) and Rotès-Quérol test (positive/negative). Inclusion criteria for GJHS were a Beighton score ≥5 and minimum one hypermobile shoulder, while NGJH was defined as a Beighton score ≤3 and no shoulder hypermobility. Three prone lying, upper-extremity weight-bearing shoulder stabilometric tests were performed on a force platform: Bilateral upper-extremity support eyes open (BL-EO) and eyes closed (BL-EC) and unilateral upper-extremity support eyes open (UL-EO). Surface electromyography (SEMG) was measured from the upper trapezius, lower trapezius, serratus anterior, infraspinatus and pectoralis major muscles. SEMG was normalized using maximal voluntary isometric contractions and presented relative to maximal voluntary SEMG (%MVE). Co-contraction index (CCI) was calculated for the following muscle pairs: upper trapezius-lower trapezius, upper trapezius-serratus anterior, and infraspinatus-pectoralis major. Between-group differences in stabilometric parameters, %MVE, and CCI were analyzed with a mixed effects model., Results: Thirty-eight swimmers were enrolled as GJHS (n = 19) or NGJH (n = 19). There were no group differences in stabilometric parameters or CCI. GJHS displayed significantly decreased (29%) pectoralis major activity during BL-EO compared to NGJH (5.35 ± 1.77%MVE vs. 7.51 ± 1.96%MVE; p = 0.043)., Significance: Adolescent competitive swimmers with GJHS displayed no shoulder sensorimotor control deficiencies and no generally altered shoulder muscle activity pattern, except for decreased pectoralis major activity in BL-EO. Longitudinal studies are needed to investigate whether decreased pectoralis major activation contributes to the development of shoulder pain in swimmers with GJHS., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Generalised Joint Hypermobility including shoulder hypermobility (GJHS) in swimmers is considered an intrinsic risk factor for shoulder injuries. The aim was to investigate the association of GJHS with shoulder strength, fatigue development and muscle activity during swimming-related shoulder rotations. Totally, 38 competitive swimmers (aged 13-17 years) participated, 19 were competitive swimmers with GJHS and 19 were age, sex and club matched swimmers without GJHS. Concentric isokinetic force in medial and lateral rotations were measured at 60°/s (5 repetitions) and 180°/s (10 repetitions). Electromyographic activity was measured from upper trapezius, lower trapezius, serratus anterior, infraspinatus and pectoralis major muscles. Swimmers with GJHS produced significantly lower peak torque (0.53 vs. 0.60 Nm/kg; p = .047) and maximum work (0.62 vs. 0.71 J/kg; p = .031) than controls during medial rotation (60°/s). Swimmers with GJHS showed significantly larger isokinetic fatigue at 180°/s (0.321 J/repetition; p = .010), and tendencies to lower levels of muscle activity in infraspinatus (20%, p = .066) and pectoralis major (34%, p = .092) at 60°/s during medial rotation. Young competitive swimmers with GJHS, despite no formal diagnosis, displayed strength and fatigue deficits in medial rotation, potentially inherent with greater risk of shoulder injury. Whether GJHS swimmers benefit from medial rotation strengthening is an important topic for future studies., (Copyright © 2018 Elsevier Ltd. All rights reserved.)