Abstract
Background
Little evidence is available regarding patient perceptions of the treatment of shoulder instability. The aim of this study is to investigate patient perceptions regarding the operative and nonoperative treatment of anterior shoulder instability.
Methods
Patients who presented to the emergency department or outpatient clinic between 2016 and 2020 were retrospectively selected using diagnosis and procedure codes. Online focus groups and semistructured interviews were conducted, systematically recorded and subsequently transcribed to MaxQDA 2007 for qualitative analysis. Coded transcripts of all focus groups were subjected to a grounded theory–based analysis.
Results
Six focus groups and two semistructured interviews were hosted with 35 included patients. The mean age of included patients was 34.1 years (±11.5). Eight patients were female (23%), and 27 patients were male (77%). Fear of (recurrent) dislocation, preoperative counseling, communication between surgeon and physiotherapists and need for a consistent postoperative rehab protocol turned out to be important patient perceptions. The most crucial factor for discontent was a lack of communication from the surgeon.
Discussion
This patient-centered focus group study revealed that fear of (recurrent) dislocation, preoperative counseling, communication between surgeons and physiotherapists and the need for a consistent postoperative rehabilitation protocol was the most frequently discussed themes.
Keywords: shoulder instability, patient perceptions, Bankart, Latarjet, fear for dislocation
Introduction
Anterior shoulder instability is frequently encountered by surgeons, emergency doctors, sports physicians, general practitioners and (physio)therapists, with an incidence between 11.2 and 56.3 per 100.000 person-years.1–5 Shoulder instability is usually classified by one or more shoulder (sub)luxation confirmed on x-ray, symptoms of instability, pain, loss of function and a positive apprehension test at physical examination. 6
Anterior instability of the shoulder may be treated both operatively and nonoperatively. 7 Nonoperative treatment may consist of temporary immobilization of the affected shoulder and physical therapy.8,9 Several operative treatment methods have been described and can be divided into soft tissue repairs (e.g. Bankart) or bone block procedures (e.g. Latarjet). 10
Over the last decade, there has been a shift from physician-centered care to patient-centered care in orthopedics. 11 Understanding patient perspectives may potentially define the successful treatment of anterior shoulder instability. Moreover, literature has shown this shift may increase efficiency in healthcare. 12 Increasing knowledge of patient perceptions could lead to better patient information provision, more focused aftercare programs, improved preoperative and postoperative counseling, and patient-centered treatment protocols (e.g. rehabilitation protocol).13,14 However, much is still unknown about these patient perceptions after treatment for shoulder instability.
In 2019, Trojan et al. evaluated the available evidence regarding patient-related expectations, outcomes, and satisfaction after operative treatment of shoulder instability. 15 The authors concluded that patients who underwent operative treatment of anterior shoulder instability have high expectations concerning postoperative functional outcomes. However, nonoperative management of anterior shoulder instability was not taken into account. The aim of this study is to investigate patient perceptions regarding the operative and nonoperative treatment of anterior shoulder instability using a qualitative methodology. Moreover, this study aims to gain insight into treatment expectations and patient satisfaction regarding the treatment of shoulder instability.
Materials and methods
Study design and setting
A focus group study was performed at the OLVG Amsterdam. Online focus groups and semistructured interviews were hosted between April 2021 and June 2021. Review board approval was obtained by the local medical ethics committee of the OLVG Amsterdam (WO21.012). All patient data and transcripts were anonymized before qualitative analysis.
Participants/study subjects
Eligible patients were identified using diagnosis and procedure codes. Adult native Dutch speakers who presented with anterior shoulder instability to either the emergency department or outpatient clinic between 2016 and 2020 were eligible for inclusion. Shoulder instability was defined in three groups according to the classification of Al-khaduhimi: 1) a radiographically confirmed dislocation or a dislocation that can be manually reduced, 2) subluxations or patient-perceived instability that can be reduced without the need for radiographically confirmation, 3) a positive apprehension (pain or weakness during external rotation and abduction of the humerus) without confirmed dislocation and spontaneous reduction, determined by at the emergency department or outpatient clinic by the orthopedic surgeon (or resident).6,16 All patients with shoulder instability undergoing operative treatment underwent preoperative imaging with magnetic resonance imaging or computed tomography to confirm glenoid labral tears or glenoid bone loss as an indication for surgical stabilization. Eligible patients received study information by e-mail. One week later, patients were invited by phone to participate in this study. Patients were included in the study after completing written informed consent.
Patient characteristics
Patient parameters were extracted from the electronic health records (EHR). Gender, age, comorbidity, date of injury, side of injury and if applicable: American Society of Anesthesiologists (ASA) classification, BMI and recurrent shoulder instability. Besides data obtained from the focus group and EHR, a short online questionnaire was sent to all participants using Castor EDC v2021.2.4 (Amsterdam, the Netherlands). The questionnaire comprised questions about employment, the number of preoperative and postoperative shoulder dislocations and patient satisfaction regarding the entire treatment using a Numeric Rating Scale (NRS).
Focus groups and script
Patients were divided into one of three groups, according to the type of treatment: A) nonoperative, B) operative (Bankart Repair) or C) operative (Latarjet Procedure). Nonoperative treatment was described as treatment with a temporary immobilization of the arm for at least one week, combined with or followed by physiotherapy. Operative treatment in group B was described as an arthroscopic re-pair of the capsule and labrum using suture anchors. Operative treatment in group C was described as open stabilization using internal autograft fixation with two cannulated screws of the coracoid process to the anterior glenoid. All patients who received operative treatment were instructed to wear a sling for six weeks. During follow-up, patients were referred to a dedicated shoulder physiotherapist for rehabilitation. All patients were treated by experienced fellowship-trained orthopedic surgeons.
The focus group script, which was made by an experienced team of researchers and medical specialists consisting of shoulder dedicated trauma and orthopedic surgeons, was based on the script previously used in a clavicular fracture population (Table 1).17,18
Table 1.
Focus group script, questions and logic.
| No. | Question | Question logic | |
|---|---|---|---|
| Free discussion | 1 | What impact did the shoulder instability have on your live before and after the treatment? | Primer |
| 2 | What were your expectations of the treatment of shoulder instability? | Contrasting expectations to actual level of care | |
| 3 | Looking back at the treatment, how satisfied are you with the treatment?
|
||
| 4 | What would your reaction have been if you were offered the other treatments (e.g., surgery instead of nonoperative treatment)? | Compare beliefs for the other treatment to actual level of care | |
| Facilitator-guided discussion | 5 | If applicable, what did you think of the treatment at the emergency department? | Dimension: process of care |
| 6 | What is your opinion about your visit(s) to the outpatient clinic and the medical staff?
|
Dimension: outcome of care | |
| 7 | What role did the physiotherapist play during your treatment of shoulder instability?
|
Dimension: process of care | |
| 8 | What do you think of the result of the treatment?
|
Dimension: outcome of care | |
| 9 | What do you think of the facilities of the hospital?
|
Dimension: structure of care | |
| Summary | 10 | Is there anything missing in our summary? | Data saturation |
The first part of the script consisted of four open questions regarding the impact of shoulder instability on daily activities, expectations prior to treatment, up- and downsides during the course of the treatment. Patients were able to freely discuss these subjects within the focus group. The second part of the script systematically probed into perceptions of preoperative and postoperative treatment phases and was guided by a moderator.
After each focus group, the script was carefully assessed and if necessary, adjusted according to patients’ feedback. One question was added after the first focus group to provide more insight into the impact of shoulder impairment in daily life (question 1 focus group script). No further additions were made to the script (Table 1).
Data collection
Data were collected during six online focus groups (two per treatment) and two semistructured interviews. Participants were intentionally separated into treatment-specific focus groups (nonoperative, arthroscopic Bankart repair and open Latarjet procedure) in order to investigate whether any differences were present in outcomes between these groups. Aiming to reach data saturation, which is the point where no new information is revealed during the focus groups, 4–8 patients per focus group and 24–48 patients in total were invited to participate in the focus groups.14,18 Additional semistructured interviews would be hosted if data saturation was not achieved. These interviews were held one-on-one using then identical script to the focus groups.
All focus groups and semistructured interviews were hosted in an online password-protected environment using Zoom 5.6.1 (San Jose, USA). Focus groups lasted for approximately 90 min. The moderator of the focus group (TI) had previous experience with patients with shoulder instability but did not have a therapeutic relationship to any of the participants. One of two observers (ET, IK) attended the focus groups to take notes and record the complete session. The script was used to guide the discussion. The moderator negotiated the group dynamic so all the participants could have their say in the focus groups. Participants were encouraged to contribute by asking direct and open questions. All focus groups and interviews were both audio and video recorded for later transcription.
Analysis
Analysis was performed thematically utilizing an inductive approach. 19 Transcripts were made for all the individual focus groups based on the audio and video recordings. These reports had a question-by-question format, with every patient represented by their own unique code. This code is composed of the abbreviation of the treatment (NO = nonoperative, ABR = arthroscopic Bankart repair, LP = open Latarjet procedure), together with the participant's gender and age. Two researchers (TI, ET) independently analyzed the transcripts. The first analytical step involved repeatedly reading the interview transcripts and becoming familiar with the content. The next step for each researcher was to independently assign a code to each text segment. These codes were then combined into themes. After initial coding, transcripts were discussed between two authors and a joint code system was created based on the initial codes of both researchers (Supplement 1). Any disagreements were resolved by discussion and consensus. Coding was performed digitally using a qualitative research software package, MaxQDA 2007, previously used in similar qualitative data studies. 20 Eventually, the coded data were converted into emerging themes by consensus of two researchers (TI, ET). Coded transcripts of all focus groups were subjected to a grounded theory based analysis, which is a theory based on a qualitative method enabling to discover new theories based on systematically obtained and analyzed data. 21
Results
A total of 239 eligible patients were asked to participate in the study (108 NO, 72 ABR, 59 LP). Of these patients, 35 patients (36 shoulders) agreed to participate in the online focus groups and semistructured interviews. Six online focus groups were hosted (two per treatment type). In addition, two semistructured interviews were held with patients in the nonoperative treatment group due to the low response rate of participants in the sixth focus group.
Participants
Demographic data of 35 participants (36 shoulders) are displayed in Table 2. The mean age during treatment was 34.1 ± 11.5 years. Eight participants were female (23%) and 27 male (77%). Most of the included patients had five or more preoperative shoulder dislocations (24/35; 69%). In 21 of 35 patients (60%), the dominant side was affected. Persistent perceived feeling of shoulder instability after treatment was present in all treatment groups (NO 63% vs. ABR 14% vs. LP 12%). Overall patient satisfaction throughout the surgically treated groups was 9/10 for ABR and 9.1/10 for LP, while the group receiving nonsurgical treatment had an overall satisfaction rate of 5.4/10.
Table 2.
Patient characteristics.
| Nonoperative (n = 8) | Operative, arthroscopic Bankart repair (n = 15) | Operative, open Latarjet procedure (n = 13) | |
|---|---|---|---|
| Age perioperative/pretreatment (years) | 43.0 years | 30.3 years | 31.3 years |
| Male gender (%) | 5 (63%) | 13 (87%) | 12 (92%) |
| Relevant comorbidities (e.g. cardiovascular or pulmonary disease) (%) | None | 1 (7%) | 1 (8%) |
| Employment with frequent overhead movements (%) | 3 (38%) | 1 (6%) | 2 (15%) |
| Number of pre-treatment shoulder dislocations (%) | |||
| • <3 times | 2 (25%) | 2 (13%) | 0 (0%) |
| • 3–5 times | 3 (38%) | 5 (33%) | 0 (0%) |
| • >5 times | 3 (38%) | 8 (53%) | 13 (100%) |
| Shoulder dislocation dominant side (%) | 5 (63%) | 8 (53%) | 8 (62%) |
| Recurrent shoulder instability (%) | 5 (63%) | 2 (14%) | 2 (12%) |
| Overall patient satisfaction with treatment (NRS) | 5.4 | 9.0 | 9.1 |
BMI: body mass index; ASA: American Society of Anesthesiologists.
Analysis
Across focus groups and semistructured interviews, four frequently discussed themes emerged: fear of (recurrent) dislocation, preoperative counseling, communication between surgeon and physiotherapists and need for a consistent postoperative rehabilitation protocol (Figure 1). The most crucial factor for discontent regarding the treatment process was a lack of communication by the surgeon. This mainly entailed too little focus on the impact of the treatment on a patient's life and too little guidance regarding the treatment instructions. Also, a lack of communication between the surgeon and physiotherapist during aftercare was a point of discontent. Patients expected more frequent interprofessional collaboration concerning expected recovery and rehabilitation plans to ensure a proper recovery.
Figure 1.
Frequently discussed themes.
Fear of (recurrent) dislocation
Fear of recurrent dislocation was one of the most-discussed themes during the focus groups. Many participants mentioned this fear when discussing treatment expectations.
LP-M24: […] I can remember […] how it felt to play sports without having to take into account that my shoulder is unstable and that it could dislocate with the slightest movement. I really wanted to go back to that situation. Training without noticing any discomfort. I also misjudged the mental repercussions the shoulder instability would have. That is something that will always be in the back of my mind.
Many participants also indicated that the fear of (recurrent) dislocation persisted after either operative or nonoperative treatment.
NO-F49: No, the fear never disappeared […] with the smallest amount of pain or sound […] you instantly think: it will happen again. It is so extremely painful. It is almost traumatic.
LP-M50: […] a sort of fear. I consciously no longer make certain movements and I do not perform any sports anymore […] imagine it would happen again, that would be horrible […] that fear is still present […] Somehow it is constantly in the back of your mind.
Other participants emphasized that fear of shoulder dislocation limited daily life both before and after their treatment, for instance with sports or overhead movements.
ABR-M28: […] that is what disappoints me the most, that the fear of dislocation is still present to date and that I feel limited in the range of motion.
NO-M45: […] the anxiety plays a big role. And you avoid certain activities because you are afraid that you fall and that the shoulder immediately dislocates. So, in that way, it controls my life. I also have to say it is very painful. […]
Several participants also mentioned that they regretted the fact that there was little attention for this fear during the treatment.
NO-F49: […] as a patient, you are already very insecure and afraid of every movement. […] I always had the feeling that there was not enough understanding from the doctors, for the fear of (recurrent) dislocation that you experience as a patient. Of course, the treatment is important. But also, what does it mean to you as a patient? What impact does it have on a person? Not only fixing the problem with the shoulder but also the fear caused by it. That is what I really missed the past 17 years […] the empathy of how to deal with these kinds of anxiety, I really missed that.
Some participants would have liked a focus group as part of the initial treatment, to learn from each other's experiences with fear and know that they are not alone in facing their problems.
ABR-F28: I would also have really liked it to be able to share my experiences with others […]. I think it would help people struggling with the same kind of problems […]
Preoperative counseling
Most participants were satisfied with the provided information by the treating orthopedic surgeon and felt taken seriously and involved in the decision-making process. Moreover, the surgeon often showed enough empathy and clearly communicated the expectations for treatment and outcomes.
ABR-M30: […].it was really nice to be taken seriously immediately […]
LP-M35: I can remember the explanations by the surgeon. That was clear to me. Also, the risks associated with the surgery […] I thought that was really clear and the result of the treatment is actually exactly how he described it back then.
Although most participants were satisfied with the communication, others expected more empathy from the surgeon during their conservation.
LP-M26: […] empathy […] maybe for him, it is a conversation he has had 100 times but for me, it is new, so you could call it a lack of empathy.
NO-F27: […] and also to create a safe environment where a patient is not afraid to share their emotions and insecurities with the doctor. Yes, of course, it matters what kind of shoulder impairment there is, but it is also important what kind of impact it has on someone’s live […]
Several participants indicated that management of expectations is important before undergoing treatment for shoulder instability. This includes being informed about the risks, the expected outcomes and the patient's own responsibilities with regard to optimizing the outcome.
LP-M35: […] I can remember the explanation of the process and to me that was very clear. And also the risks and expectations of the treatment were very realistic […]
Moreover, preoperative physiotherapy was a frequently discussed theme when talking about expectation management with patients who underwent surgery. Participants suggested these appointments prior to surgery to be standard care, both for making a rehabilitation plan and to increase muscle strength and endurance before going proceeding with surgery.
ABR-M39: In my case, I was subject to preoperative assessment by the physiotherapist. In the appointments before the surgery, he explained to me what was going to happen and what plan he had for the recovery process. That gave a lot of reassurance before going into surgery […] I really appreciated that preparation.
Post-treatment guidance
Almost all participants indicated the postoperative period with physiotherapy as an important phase of their treatment. The physiotherapist was felt to play a key role during the recovery process of rebuilding muscle strength and trust.
ABR-M29: […] building trust That is what has been the biggest step for me […] the physiotherapist has played such a huge role in my recovery […] my conclusion is that good physiotherapy is so extremely important for your progress.
LP-M31: That is what has been the most important to re-build that trust […] the more I started to train my shoulder, the more it started to regain its stability and that enabled me to do crazy things without any struggle […]
However, various participants were dissatisfied with the communication between the physiotherapist and the surgeon. They felt as if this collaboration was insufficient and some even felt that it caused a feeling of insecurity.
ABR-M35: […] for me it was really unclear at what moment the physiotherapist should have provided the doctor information and otherwise. […] That communication pathway was really unclear. As a patient, you expect more from that interaction.
LP-M24: […] in general, as a patient, you are dependent on the physiotherapist during rehabilitation and that part of the treatment is not really monitored by the hospital. And we, as patients, do not have enough knowledge to make that judgment call. And in that capacity, I agree with what has been said about the insufficient interaction between the surgeon and the physiotherapist […]
Another participant felt that there was no standard of (after)care when visiting multiple different physiotherapists, which unnecessarily prolonged her recovery.
NO-M45: […] what struck me is that with physiotherapy […] all three therapists had a totally different story and a different treatment. So, for me, it is not really clear if there is a standard policy for the rehabilitation […] also, that is something that did not help me throughout the process […]
Several participants wished to receive more guidance from the hospital when considering which physiotherapist to go to.
NO-F44: […] that would be nice if they give you more guidance. That they would say, this is a specialist in this field of work and I would urge you to go to that therapist and not just choose a random physiotherapist with basic knowledge […] if they know this is the best, that they should say it more confidently […]
Other topics
During the focus groups, the moderator brought up multiple topics including: waiting time(s) at the outpatient clinic, travel distance, parking and accessibility. Overall participants in all focus groups indicated that their patient experience was not dependent on these topics.
Discussion
The aim of this focus group study was to gain insights into patient perceptions after both operative and nonoperative treatment of anterior shoulder instability. Irrespective of treatment modality, the most frequently discussed themes were fear of recurrent dislocation, preoperative counseling, communication between surgeon and physiotherapists and need for a consistent postoperative rehabilitation protocol. Themes were comparable across all focus groups and subsequently between the three different types of treatment. Participants frequently expressed fear and anxiety when discussing the impact of shoulder instability, treatment expectations, treatment outcomes and the role of physiotherapy in the restoration of trust in their affected shoulder. Moreover, participants stated that this fear often persisted even after their treatment. Participants reported limitations in daily life and with activities such as sports and work. In addition, some participants regretted that fear was a minor subject of discussion with their treating surgeon throughout the treatment.
For the purpose of this study, a focus group design was used, which contains the following limitations. 22 First, patients who received nonoperative treatment were less interested in participating in the study. Only 8% of the identified patients receiving nonoperative treatment participated in this study, compared to 21% (ABR) and 22% (LP) for patients receiving operative treatment. As a consequence, two additional semistructured interviews were hosted. As these interviews do not have the same interactive aspect as a focus group, this might potentially limit the amount of information derived from those sessions. Second, the age range of the patients included in this study is not entirely representative of the wider population of patients with shoulder instability. The average age of the patients in this study was relatively high at 34.1 years, with most studies investigating the epidemiology of shoulder instability reporting an average age below 30 years.2–5 Third, this study held focus groups using an online videoconferencing platform instead of face-to-face focus groups due to nationwide COVID-19 restrictions. The video conference allowed for nonverbal interaction between participants, minimalizing the difference with face-to-face focus groups. Finally, this design is potentially subject to recall bias. Since we included participants from 2016 to 2020, participants had to rely on their memories of the treatment. Furthermore, patients were specifically questioned if they remembered subjective feelings of recurrence after surgery. This may explain the relatively high number of recurrences among surgically treated patients. Although there are limitations, this study was the first study to evaluate patient perceptions after the treatment of shoulder instability using a focus group design, allowing for interactive group discussion. It provides a unique insight into patient perceptions.
Consistent with previous literature, participants considered the restoration of a stable shoulder an important theme.23–25 However, these studies did not reveal that fear of instability may play the most important role in these expectations. The current study shows that participants favor the disappearance of fear of recurrent dislocation as the most important outcome, even over a shoulder dislocation. This fear differs from apprehension. Apprehension is the fear of imminent dislocation when placing the arm in abduction and external rotation. The fear the participants of this study described throughout all focus groups is one that is persistent in its presence. This fear, and in particular the fear-avoidance, was already described in 2000 by Vlaeyen and Linton. This model suggested that weakness and limited physical activity cause fear-avoidance. 26 However, other researchers assume that unstable shoulders have a significantly decreased proprioceptive ability, making it vulnerable of recurrent shoulder instability. 27
Among participants receiveing nonoperative treatment, overall satisfaction was lower than those receiving operative treatment. This may be caused by the increased number of recurrent shoulder dislocations compared to participants treated operatively, potentially thereby affecting the fear of (recurrent) dislocation. In addition, most nonoperatively treated participants did not perceive being prescribed a sling as a type of real treatment, presumably because of a lack of guidance throughout the treatment process. This finding is consistent with previous focus group research on patient experiences after nonoperative treatment for clavicle fractures. 18 This suggests the need for improved information on nonoperative treatment.
Physiotherapists were often praised during the focus groups for their role in the treatment. However, many patients were dissatisfied with the interaction between their surgeon and their physiotherapist, indicating a lack of communication as the most important factor for discontent. This could also be caused by a lack of universal post-treatment protocols. This is in line with findings from previous studies, where lack of information was the major cause of dissatisfaction.18,28 A study by Longstaffe et al. in 2015 showed that surgeons and physiotherapists reported a negative view of their interprofessional communication. 29 Both surgeons and physiotherapists in this study did often disagree on information provided to patients concerning several aspects of rehabilitation, such as the aim of treatment and referral criteria. Moreover, participants across all focus groups expected a more dominant role from the hospital in referring to a (specific) physiotherapist.
Future studies are needed to further investigate patient perceptions and satisfaction and should specifically focus on fear of (recurrent) dislocation and the role of physiotherapy. Ideally, this should lead to an integrated patient-centered care model where both surgeons and physiotherapists work alongside similar treatment plans in order to deliver optimal care.
Conclusions
This patient-centered focus group study revealed that fear of (recurrent) dislocation, preoperative counseling, communication between surgeons and physiotherapists and the need for a consistent postoperative rehabilitation protocol was the most frequently discussed themes.
Supplemental Material
Supplemental material, sj-docx-1-sel-10.1177_17585732221122363 for Patient perceptions after the operative and nonoperative treatment of shoulder instability: A qualitative focus group study by Theodore P van Iersel, Eric D Tutuhatunewa, Ithri Kaman, Bas A Twigt, Sigrid NW Vorrink, Michel PJ van den Bekerom and Derek FP van Deurzen in Shoulder & Elbow
Footnotes
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Theodore P van Iersel https://orcid.org/0000-0003-1892-0780
Supplemental Material: Supplemental material for this article is available online.
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Supplementary Materials
Supplemental material, sj-docx-1-sel-10.1177_17585732221122363 for Patient perceptions after the operative and nonoperative treatment of shoulder instability: A qualitative focus group study by Theodore P van Iersel, Eric D Tutuhatunewa, Ithri Kaman, Bas A Twigt, Sigrid NW Vorrink, Michel PJ van den Bekerom and Derek FP van Deurzen in Shoulder & Elbow