***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND The prevalence and risk factors for recurrent instability and functional impairment following a primary glenohumeral dislocation remain poorly defined in younger patients . We performed a prospect i ve cohort study to evaluate these outcomes . We also aim ed to produce guidelines for the design of future clinical trials , assessing the efficacy of interventions design ed to improve the outcome after a primary dislocation . METHODS We performed a prospect i ve cohort study of 252 patients ranging from fifteen to thirty-five years old who sustained an anterior glenohumeral dislocation and were treated with sling immobilization , followed by a physical therapy program . Patients received regular clinical follow-up to assess whether recurrent instability had developed . Functional assessment s were made and were compared for two subgroups : those who had not had instability develop and those who had received operative stabilization to treat recurrent instability . RESULTS On survival analysis , instability developed in 55.7 % of the shoulders within the first two years after the primary dislocation and increased to 66.8 % by the fifth year . The younger male patients were most at risk of instability , and 86.7 % of all of the patients known to have recurrent instability had this complication develop within the first two years . A small but measurable degree of functional impairment was present at two years after the initial dislocation in most patients . Sample -size calculations revealed that a relatively small number of patients with a primary dislocation would be required in future clinical trials examining the effects of interventions design ed to reduce the prevalence of recurrent instability and improve the functional outcome . CONCLUSIONS Recurrent instability and deficits of shoulder function are common after primary nonoperative treatment of an anterior shoulder dislocation . There is substantial variation in the risk of instability , with younger males having the highest risk and females having a much lower risk . Future clinical trials to evaluate primary interventions should evaluate the prevalence of recurrent instability and functional deficits , with use of an assessment tool specifically for shoulder instability , during the first two years after the initial dislocation BACKGROUND We aim ed to compare the effectiveness of immobilization in abduction and external rotation vs immobilization in adduction and internal rotation after primary anterior dislocation of the shoulder . METHODS The study r and omized 102 patients ( age range , 15 - 55 years ) with the diagnosis of primary anterior dislocation of the shoulder to receive immobilization in adduction and internal rotation ( AdIR , n = 51 ) using sling and swathe b and age or immobilization in abduction and external rotation ( AbER , n = 51 ) with a stabilizer brace . Patients received a rehabilitation program 3 weeks after the intervention . RESULTS After a 24-month follow-up , 33.3 % in the AdIR group and 3.9 % in the AbER group had recurrence ( P < .001 ) . The difference in the recurrence rate was greater in the subgroup aged between 31 and 40 years ( 44.8 % in the AdIR group and 3.8 % in the AbER group , P < .001 ) . Ten patients in the AbER group ( 19.6 % ) and 3 in the AdIR group ( 5.8 % ) discontinued shoulder immobilization before 3 weeks ( P = .03 ) . In patients without recurrence , the anterior apprehension test was positive in 6 of 34 in the AdIR group ( 17.6 % ) and in 4 of 49 in the AbER group ( 8.1 % , P = .19 ) . CONCLUSIONS Immobilization with the shoulder joint in abduction and external rotation is an effective method to reduce the risk of recurrence after primary anterior shoulder dislocations and should be preferred to the traditional method of immobilization in adduction and internal rotation in clinical practice Background Anterior shoulder dislocation is a common injury and may have considerable impact on shoulder-related quality of life ( QoL ) . If not warranted for initial stabilising surgery , patients are mostly left with little to no post-traumatic rehabilitation . This may be due to lack of evidence -based exercise programmes . In similar , high-impact injuries ( e.g. anterior cruciate ligament tears in the knee ) neuromuscular exercise has shown large success in improving physical function and QoL. Thus , the objective of this trial is to compare a nonoperative neuromuscular exercise shoulder programme with st and ard care in patients with traumatic anterior shoulder dislocations ( TASD ) . Methods / design R and omised , assessor-blinded , controlled , multicentre trial . Eighty patients with a TASD will be recruited from three orthopaedic departments in Denmark . Patients with primary or recurrent anterior shoulder dislocations due to at least one traumatic event will be r and omised to 12 weeks of either a st and ardised , individualised or physiotherapist-supervised neuromuscular shoulder exercise programme or st and ard care ( self-managed shoulder exercise programme ) . Patients will be stratified according to injury status ( primary or recurrent ) . Primary outcome will be change from baseline to 12 weeks in the patient-reported QoL outcome question naire , the Western Ontario Shoulder Instability Index ( WOSI ) . Discussion This trial will be the first study to compare the efficacy and safety of two different nonoperative exercise treatment strategies for patients with TASD . Moreover , this is also the first study to investigate nonoperative treatment effects in patients with recurrent shoulder dislocations . Lastly , this study will add knowledge to the shared decision-making process of treatment strategies for clinical practice .Trial registration Clinical Trials.gov , identifier : NCT02371928 . Registered on 9 February 2015 at the National Institutes of Health Clinical Trials Protocol Registration System • STUDY DESIGN : Prospect i ve cohort study . • BACKGROUND : Patient‐reported outcome measurements ( PROMs ) are widely used to evaluate functional limitations . Considering PROMs for shoulder instability , information is lacking with regard to what constitutes a relevant change from baseline scores . • OBJECTIVES : To evaluate the responsiveness of the Western Ontario Shoulder Instability Index ( WOSI ) and the  Oxford Shoulder Instability Score ( OSIS ) and estimate their minimal important change ( MIC ) . • METHODS : One hundred five consecutive patients with shoulder instability completed 5 PROMs at baseline and at 6‐month follow‐up . The PROMs included the  WOSI and OSIS , the Simple Shoulder Test , the Oxford Shoulder Score , and the Disabilities of the Arm , Shoulder and H and assessment .  Patients also rated their functional change on an anchor question at follow‐up . Responsiveness was evaluated by testing 9 hypotheses regarding predefined correlations between the changes in PROM scores , by calculating the area under the receiver operating characteristic curve and by calculating the st and ardized response mean and effect size statistics . The MIC was determined by identifying the optimal cutoff on the receiver operating characteristic curve . • RESULTS : Seven out of 9 hypotheses ( 78 % ) were confirmed ; as expected , a high correlation ( 0.77 ) was found between change scores of the WOSI and OSIS , whereas the correlations of the change scores of the WOSI and OSIS with those of general shoulder PROMs were slightly lower ( 0.61‐0.75 ) . The area under the curve was 0.83 ( 95 % confidence interval : 0.75 , 0.91 ) for the OSIS and 0.82 ( 95 % confidence interval : 0.74 , 0.90 ) for the WOSI . The MIC was about 6 points for the OSIS and about 14 points for the WOSI . • CONCLUSION : Both the WOSI and OSIS are able to measure change in shoulder function in patients with shoulder instability . The estimated MIC is 6 points for the OSIS ( on a scale from 0 to 48 ) and 14 points for the WOSI ( on a scale from 0 to 100 ) . •KEY WORDS : clinimetrics , functional outcome measures , outcome assessment , Background It is still not clear which method is the most efficient for treating primary traumatic anterior shoulder dislocation .  Immobilization in external rotation has become increasingly discussed within the last 10 years . The aim of this study was to evaluate the rate of recurrence and clinical outcome of the immobilization in external rotation after primary traumatic anterior dislocation within a midterm period of 5 years . Additionally , a summary of literature is given according to the present knowledge of this issue . Methods From May 2004 to May 2006 , 28 patients with primary traumatic anterior shoulder dislocations were included in a prospect i ve MRI-controlled study . After a follow-up of 5 years , the recurrence rate and clinical outcomes of the patients were evaluated using clinical scores ( Constant and Murley score , Western Ontario Shoulder Instability Index , Rowe score ) . Results After 5 years , 26 patients ( 93 % ; males , n = 25 ; female , n = 1 ; mean age , 29.3 years ) were interviewed concerning re-dislocations . In the meantime , four patients ( 15 % ) experienced a re-dislocation ( ø 12.2 months ) after the end of the immobilization . Overall , 21 patients ( 75 % ) were included in a clinical follow-up ( CM score : ø 92.8 points ; Western Ontario Shoulder Instability Index : ø 87 % ; Rowe score ( in 17 patients ): ø 94.2 points ) . Upon clinical examination , unidirectional anterior instability was found in one patient , which corresponds to an overall instability rate of 19 % within the examined patient population including the re-dislocations . Conclusions Immobilization in external rotation shows satisfactory results after 5 years in regard to recurrence and instability rates and clinical outcomes . The data show that with immobilization in external rotation , re-dislocations occur within the first 2 years Two hundred and forty-five patients who had had 247 primary anterior dislocations of the shoulder were followed for ten years in a multicenter study at twenty-seven Swedish hospitals . The ages of the patients at the time of the dislocation ranged from twelve to forty years . The patients were assigned to one of three treatment groups : immobilization with the arm tied with a b and age to the torso for three to four weeks after reduction of the dislocation ; use of a sling , which was discontinued after the patient was comfortable ; or immobilization for various duration s. At the ten-year follow-up evaluation , no additional dislocation had occurred in 129 shoulders ( 52 per cent ) . Recurrent dislocation necessitating operative treatment had developed in fifty-eight shoulders ( 23 per cent ) : thirty-four ( 34 per cent ) of the ninety-nine shoulders in patients who were twelve to twenty-two years old , sixteen ( 28 per cent ) of the fifty-seven shoulders in patients who were twenty-three to twenty-nine years old , and eight ( 9 per cent ) of the ninety-one shoulders in patients who were thirty to forty years old . Twenty-four ( 22 per cent ) of the shoulders that had had at least two recurrences during the first two or five years seemed to have stabilized spontaneously without operative intervention at ten years . Dislocation of the contralateral shoulder occurred in association with sixteen ( 16 per cent ) of the ninety-nine shoulders in patients who were twelve to twenty-two years old , twelve ( 21 per cent ) of the fifty-seven shoulders in patients who were twenty-three to twenty-nine years old , and only three ( 3 per cent ) of the ninety-one shoulders in patients who were thirty to forty years old . The type and duration of the initial treatment had no effect on the rate of recurrence .  Radiographs , made for 185 shoulders at the time of the primary dislocation , demonstrated an evident Hermodsson ( Hill-Sachs ) lesion in ninety-nine shoulders ( 54 per cent ) ; this finding was associated with a significantly worse prognosis with regard to recurrence than was no evident lesion ( p < 0.04 ) . Radiographs made for 208 shoulders at the ten-year follow-up examination were evaluated for post-dislocation arthropathy . Twenty-three shoulders ( 11 per cent ) had mild arthropathy and eighteen ( 9 per cent ) had moderate or severe arthropathy . Some of the shoulders that had arthropathy had had no recurrence BACKGROUND An initial anterior dislocation of the shoulder becomes recurrent in 66 % to 94 % of young patients after immobilization of the shoulder in internal rotation .  Magnetic resonance imaging and studies of cadavera have shown that coaptation of the Bankart lesion is better with the arm in external rotation than it is with the arm in internal rotation . Our aim was to determine the benefit of immobilization in external rotation in a r and omized controlled trial . METHODS One hundred and ninety-eight patients with an initial anterior dislocation of the shoulder were r and omly assigned to be treated with  immobilization in either internal rotation ( ninety-four shoulders ) or external rotation  ( 104 shoulders ) for three weeks . The primary outcome measure was a recurrent dislocation or subluxation . The minimum follow-up period was two years . RESULTS The follow-up rate was seventy-four ( 79 % ) of ninety-four in the internal rotation group and eighty-five ( 82 % ) of 104 in the external rotation group . The compliance rate was thirty-nine ( 53 % ) of seventy-four in the internal rotation group and sixty-one ( 72 % ) of eighty-five in the external rotation group ( p = 0.013 ) . The intention-to-treat analysis revealed that the recurrence rate in the external rotation group ( twenty-two of eighty-five ; 26 % ) was significantly lower than that in the internal rotation group ( thirty-one of seventy-four ; 42 % ) ( p = 0.033 ) with a relative risk reduction of 38.2 % . In the subgroup of patients who were thirty years of age or younger , the relative risk reduction was 46.1 % . CONCLUSIONS Immobilization in external rotation after an initial shoulder dislocation reduces the risk of recurrence compared with that associated with the conventional method of immobilization in internal rotation . This treatment method appears to be particularly beneficial for patients who are thirty years of age or younger Background 
    Output:
    
Thus this result covers the possibility of a benefit for each intervention .
The available evidence from r and omised trials is limited to that comparing immobilisation in external versus internal rotation .
Overall , the evidence is insufficient to draw firm conclusions about whether immobilisation in external rotation confers any benefit over immobilisation in internal rotation .