Results and thoughts on “Exercise prescription for overhead athletes with shoulder pathology: a systematic review with best evidence synthesis.” (Wright et al., 2018)

This interesting review summarizes the evidence on exercise prescription for overhead athletes with shoulder pathology. The authors included 6 level I-IV studies and 33 level V studies. They extracted a list of exercises from these studies and assigned them to 4 categories (accessible in online version). Studies were assessed for risk of bias and scored for level of evidence. Depending on the number and the quality of the studies supporting each category, the strength of recommendation was identified:

1. Open chain upper extremity exercise performed below 90° of elevation: level B
2. Closed chain  upper  extremity  exercises: level B
3. Open chain upper extremity exercises performed above 90° of elevation: level C
4. Isokinetic exercises of the upper extremity, plyometric exercises, kinetic chain/core/lower extremity  exercises  and  sport-specific  training: level D

(A  signifies  consistent  findings  in >2 level I  studies;  B—consistent findings  in >2 level II  or  III  studies  or ≤2 level I  studies;  C—findings  from >2 level IV  studies  or ≤2 level II  or  III  studies; D—findings  from >2 level V  studies;  and  F—conflicting  findings or findings from ≤2 level V studies.)

We need to be aware that the use of plyometrics and sport-specific training is supported  by expert  opinion  alone  (these  exercises  have  not  been  subject of longitudinal effect studies),  which  is  surprising given the frequent use in practice and the obvious clinical rationale. The question remains if research will ever be able to capture the complexity of individual athlete needs. Every case is unique, has a different type of shoulder pain, different functional complaints, different shoulder impairments, plays a different sports, has a different position on the field and uses different motor control strategies. It might be valuable to develop exercise selection algorythms for overhead athlete shoulder training from clinical expertise and investigate effectiveness when working with these selection rules. The current policy of “trial and error” repetition of studies with a fixed list of exercises starting overnew each time with a different list complicates comparison between studies and postpones evidence based practice.

Reference: Wright AA, Hegedus EJ, Tarara DT, Ray SC, Dischiavi SC. 2018 Exercise prescription for overhead athletes with shoulder pathology: a systematic review with best evidence synthesis. Br J Sports Med, 52:231–237.

Author: Annelies Maenhout