title: The natural course of shoulder instability and treatment trends: a systematic review.
abstract: BACKGROUND
  The natural course of shoulder instability is still not entirely clear. We aimed in this review to analyse the current scientific evidence of the natural history of shoulder instability.
  
  
  METHODS
  A systematic review of the English literature was performed using the PubMED database throughout January 2014. This review was guided, conducted and reported according to PRISMA criteria. The criteria for inclusion in the study were (1) the article was written in English, (2) the level of evidence was 1-4, (3) the article was available in full text, (4) the article investigated the natural history or course of shoulder instability, the outcome of non-operative management, or the regression of the shoulder symptoms to the mean. The methodological quality of each included study was individually assessed using a newly developed general assessment tool-Assessing the Methodological Quality of Published Papers (AMQPP).
  
  
  RESULTS
  Eight articles related to shoulder instability met the inclusion criteria. Four papers were considered high-quality studies (evidence level 1 and 2). One paper assessed the natural history and the natural course of shoulder instability directly. The other studies indirectly assessed the natural history by studying non-operative and operative therapy trends. We found no articles which clearly referred to the role of 'regression to the mean'.
  
  
  CONCLUSIONS
  Following the natural history and the implementation of standardised non-operative treatment programmes are an effective therapy and superior to surgery in many cases. However, primary acute shoulder dislocation in young active individuals partaking in demanding physical activities could benefit from early surgical intervention. The AMQPP score works as a quick quality-checking tool which helps researchers to identify the key points in each paper and reach a decision regarding the eligibility of the paper more easily. The AMQPP scoring system is still open for further development and expansion. Level of evidence Level IV.
authors.affiliation: Department of Traumatology and Hand Surgery, Klinikum Bremerhaven Reinkenheide, Postbrookstr. 103, 27574, Bremerhaven, Germany. walid.eljabu@doctors.org.uk.
authors.forename: W
authors.initials: W
authors.lastname: Eljabu
authors.affiliation: Department of Orthopaedics, Göttingen University Hospital, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
authors.forename: H M
authors.initials: HM
authors.lastname: Klinger
authors.affiliation: Department of Orthopaedics and Shoulder Surgery, Osterholz County Hospital, Am Krankenhaus 4, 27711, Osterholz-Scharmbeck, Germany.
authors.forename: M
authors.initials: M
authors.lastname: von Knoch
mesh_terms: D006801:Humans; D007593:Joint Instability / Q000209:etiology* / Q000628:therapy*; D019637:Orthopedic Procedures; D018579:Patient Selection; D012783:Shoulder Dislocation / Q000209:etiology* / Q000628:therapy*
keywords: AMQPP assessment tool; Natural course; Natural history; Regression to the mean; Shoulder dislocation; Shoulder instability