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Oxford chair vs. traditional treatment of acute shoulder dislocation
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January 2014
Oxford chair vs. traditional treatment of acute shoulder dislocation
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A
The effectiveness of a specially designed shoulder chair for closed reduction of acute shoulder dislocation in the emergency department: a randomised control trial
Emerg Med J. 2013 Oct;30(10):795-800Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
60 patients, over 18 years of age, who were diagnosed with anterior or posterior glenohumeral shoulder dislocation were randomly assigned into one of two groups to compare the efficacy of shoulder reduction treatment with the Oxford chair (group 1) to a traditional shoulder reduction treatment (group 2). Results of the study indicated that there were no differences between the groups with regards to length of stay in the emergency department, procedure time, or pain experienced before or after treatments were completed. However, a significant difference in success rate was found, favouring the traditional treatment group over the Oxford chair method.
Publication Funding Details
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Funding:
Non-Industry funded
Sponsor:
Hong Kong College of Emergency Medicine Research Grant
Conflicts:
None disclosed
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
4/4
Randomization
3/4
Outcome Measurements
2/4
Inclusion / Exclusion
4/4
Therapy Description
4/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Acute shoulder dislocation is a common occurrence that often leads to treatment in the emergency department. A variety of managements currently exist for shoulder dislocation, but no single method has been shown to be superior to another, and most require analgesia or sedation to reduce the pain experienced during the treatment. Shoulder reduction without anesthesia has been discussed as a possible alternative by various studies, and multiple reports have been completed attempting to demonstrate a painless procedure without any premedication. Patient comfort and relaxation are influential factors in a successful shoulder reduction, and a new shoulder reduction method using a specifically designed chair (Oxford Chair), potentially offers this to patients receiving the procedure. The goal of this study was to compare the efficacy of shoulder reduction treatment with the Oxford chair to a conventional shoulder reduction treatment.
What was the principal research question?
How does the efficacy of shoulder reduction treatment with the Oxford chair compare to a conventional shoulder reduction treatment?
Study Characteristics
-
Population:
60 patients, > 18 years of age, with a diagnosis of anterior or posterior glenohumeral shoulder dislocation who were at least 150 cm tall.
Intervention:
Shoulder chair group: Patients in this group had their shoulder reduction performed by emergency physicians or nurse practitioners. Sedation was not administered due to concerns about its use in unsupported patients in a sitting position. A video clip demonstrating the technique used for the Oxford chair was provided as training material and hands on practice included. The front rest of the chair was positioned at a 45 degree angle, and patients were instructed to sit on the chair with there anterior chest wall laying prone on the front rest. The affected arm was rested with the axilla placed over the tip of the front rest and relaxation techniques performed (dimmed lights and soft talking). Once the patient was relaxed, the treating doctor or nurse grasped the patients forearm and applied longitudinal traction in conjunction with gravity. The operator was allowed to apply gentle external rotation to the shoulder in order to facilitate joint reduction. Patients were treated with the traditional method after three attempts or if they asked to be sedated. (Mean age: 43.7 +/-22.51, n= 30, 30 completed follow up, F=17/M=13).
Comparison:
Traditional practice group: Patients in this group received any recognised method for closed reduction according to the emergency clinicians' preference and clinical judgement. Kocher's manoeuver was suggested as a primary reduction technique by the authors of the study, but this did not mean that all patients were treated with that method. Oral Paracetamol (1g) and rescue analgesia of intravenous morphine (2mg) was given to patients on request (Mean age: 50.1 +/- 23.15, n=30, 30 completed follow up, F=10/M=20).
Outcomes:
The primary outcome measured in this study was the length of patient stay in the emergency department. The secondary outcomes measured in this study were: length of procedure, successful reduction rate, and pain levels experienced before and after treatment.
Methods:
RCT: Single Center
Time:
Measurements were taken until patients were discharged from the emergency department.
What were the important findings?
- 7 failed reductions occurred in the Oxford chair group following treatment. These patients went on to have successful reduction with the traditional method. Only 1 patient failed reduction in the traditional method group.
- Median length of stay in the emergency department was 152 min in the oxford chair group compared to 173 min in the traditional group, however this difference was not significant (p=0.183)
- Median procedure time was 3 min in the oxford chair group compared to 5 min in the traditional group (p=0.179).
- When comparing groups on a per-protocol basis, a significantly shorter procedure time for the Oxford chair group was found compared to the traditional treatment group (2 min vs. 6 min, respectively) (p<0.001).
- Success rate was 97% for the traditional group and 77% in the Oxford chair group, showing a significantly higher success rate in the traditional treatment group (p=0.023).
- No differences between the groups was shown regarding average pain experienced at baseline, 30 min after oral analgesic, during the procedure, or at discharge (p>0.05).
- When patients who experienced successful reduction in their first treatment were compared between groups, it was found that patients in the Oxford chair group had significantly less time to reduction (2 min vs. 5 min) (p=0.008), and length of stay (125 min vs. 180) (p=0.025) than those in the traditional treatment group.
What should I remember most?
Median length of stay and median procedure time was not significantly different between groups. The success rate for the oxford chair was significantly lower than the traditional treatment method. No statistically significant differences were found in pain score at any point.
How will this affect the care of my patients?
Results of this study found that traditional treatment methods for shoulder reduction resulted in a significantly higher success rate than those treated with the Oxford chair method. No differences were found between treatment methods regarding length of stay, procedure time, and pain experienced before or after treatment. Patient factors, such as those who have had precious shoulder surgery or fracture dislocations may have affected the results of this study. Further research is needed to clearly identify the effect the Oxford chair treatment method on acute shoulder dislocations.
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