title: The effect of exercise-based management for multidirectional instability of the glenohumeral joint: a systematic review.
abstract: BACKGROUND
  The most commonly recommended treatment for multidirectional instability (MDI) of the glenohumeral joint is exercise-based management. The primary objective of this review was to evaluate the effectiveness of exercise-based management in patients with MDI. The secondary aim was to observe the types of exercise protocols and outcomes used, as well as any adverse results associated with exercise.
  
  
  METHODS
  The Cochrane Database of Systematic Reviews, Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PEDro, Current Contents, Allied and Complementary Medicine (AMED), Australasian Medical Index (AMI), Ausport, and Clinical Trials Registers were searched for published and unpublished studies from the inception date to June 2012 using the keywords multidirectional instability, glenohumeral, and exercise. Selection criteria included all study designs (except case reports and case series) and participants with clinically diagnosed MDI using exercise-based management. Inclusion criteria were not limited by outcomes. The authors' own risk-of-bias tool was used for quality assessment of studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to synthesize the evidence.
  
  
  RESULTS
  The risk of bias was high in all 7 included studies. For before-and-after comparisons of exercise-based management, GRADE assessment showed very low-quality evidence for improvements in shoulder kinematics, the Rowe score, overall status rating, and peak muscle strength.
  
  
  CONCLUSIONS
  The effect of exercise-based management on MDI was variable across the included studies because of study heterogeneity and a high level of bias. There is a need for high-quality intervention studies to be undertaken to validate the effect of exercise for MDI.
authors: Department of Physiotherapy, Faculty of Health Sciences, La Trobe University, Bundoora, VIC, Australia. Electronic address: sarahannwarby@gmail.com.
authors: Sarah A
authors: SA
authors: Warby
authors: Department of Physiotherapy, Faculty of Health Sciences, La Trobe University, Bundoora, VIC, Australia.
authors: Tania
authors: T
authors: Pizzari
authors: Musculoskeletal Research Centre, Department of Physiotherapy, Faculty of Health Sciences, La Trobe University, Bundoora, VIC, Australia.
authors: Jon J
authors: JJ
authors: Ford
authors: Musculoskeletal Research Centre, Department of Physiotherapy, Faculty of Health Sciences, La Trobe University, Bundoora, VIC, Australia.
authors: Andrew J
authors: AJ
authors: Hahne
authors: Musculoskeletal Research Centre, Department of Physiotherapy, Faculty of Health Sciences, La Trobe University, Bundoora, VIC, Australia; LifeCare Prahran Sports Medicine Centre, Prahran, VIC, Australia.
authors: Lyn
authors: L
authors: Watson
mesh_terms: D000328:Adult; D005081:Exercise Therapy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D007593:Joint Instability / Q000628:therapy*; D053580:Muscle Strength; D012783:Shoulder Dislocation / Q000628:therapy*; D012785:Shoulder Joint; D016896:Treatment Outcome
keywords: Level IV; Multidirectional instability; Systematic Review; exercise-based management; glenohumeral; impairment; patient focused; shoulder