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List of Abbreviations
From the Departments of General Practice (Gebremariam, Koes, Huisstede); and
Rehabilitation Medicine (Huisstede), Erasmus MC University Medical Center
Rotterdam, Rotterdam, The Netherlands; the Arthritis Research Campaign National
Primary Care Centre, Keele University, Keele, United Kingdom (Hay).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.
Reprint requests to Bionka M.A. Huisstede, PhD, Erasmus MC University
Medical Center Rotterdam, Dept of Rehabilitation, Room H-016, PO Box 2040, 3000
CA Rotterdam, The Netherlands, e-mail: b.huisstede@erasmusmc.nl.
0003-9993/11/9211-00260$36.00/0
doi:10.1016/j.apmr.2011.06.006
ASD
ASES
CANS
OSD
PLG
RCT
ROM
SIS
UCLA
1901
Study Selection
Two reviewers (L.G. and B.H.) independently applied the
inclusion criteria to select potential relevant studies from the
title and abstracts of the references retrieved by the literature
search. A consensus method was used to solve any disagreements concerning inclusion of studies, and a third reviewer
(B.K.) was consulted if disagreement persisted.
Categorization of the Relevant Literature
Relevant literature is categorized under 3 different headers:
Systematic reviews describes all (Cochrane) reviews; Recent
RCTs contains all RCTs published after the search date of the
systematic review on the same intervention; Additional RCTs
1902
Abbreviations: , yes; -, no; ?, unclear/unsure; ITT, intention-to-treat; NA, not applicable (in a nontime intervention, eg, surgery, compliance is not an issue).
33
4
?
?
?
12
42
5
12
42
5
12
55
6
NA
11
82
9
11
NA
Everts
et al26
Taverna
et al25
Hultenheim
Klintberg
et al27
Jarvela
et al29
Hoe-Hansen
and
Norlin28
Reference
Blinding?
Outcome
Assessors?
Blinding?
Patients?
Adequate
Randomization?
Allocation
Concealment?
Blinding?
Caregiver?
Score
Study
Cointerventions
Avoided or
Similar?
Free of
Suggestions
Similarity of
of Selective
Baseline
Outcome
Reporting? Characteristics?
Incomplete
Outcome
Data? ITT
Analysis?
Incomplete
Outcome
Data
Addressed?
Dropouts?
Table 3: Methodologic Quality Scores of the Included Recent and Additional RCTs
Timing of
the
Outcome
Compliance
Acceptable in Assessment
Similar?
all Groups?
Maximum
Score
Methodologic Quality
Tables 3 and 4 present the results of the methodologic
quality assessment.
Two of the 5 included RCTs were classified as high quality.
The 3 low-quality RCTs scored 33% to 42% of the total score.
The most prevalent methodologic flaws were: (1) care provider
not blinded (75%) (as expected in surgery) and (2) no intention-to-treat analysis (75%) was applied by the authors of the
RCTs. According to the authors of the Cochrane review,11 10
of the 11 RCTs had a high risk of bias, and 1 RCT had a
medium to high risk of bias; 6 items were used to score the
methodologic quality of these studies.
Effectiveness of Surgical and Postsurgical Interventions
to Treat SIS
A complete overview of the evidence is presented in table 5.
1. Effectiveness of Surgery
1.1. Arthroscopic or Open Subacromial Decompression
Versus Conservative Treatment
Systematic review. Three trials (n258) compared either
open14 or arthroscopic15,16 surgery with active nonoperative
treatment. The low-quality study of Haahr et al16 (n90) found
no differences between arthroscopic subacromial decompression and a graded physiotherapy strengthening program on the
mean change in Constant score at 3, 6, and 12 months. Furthermore, there were no significant differences between the 2
treatment groups for the PRIM score (aggregated pain and
dysfunction score used in Projects on Research and Intervention in Monotonous work) at 12 months, or between the number of participants with a good or excellent Constant score
(80) at 12 months.
A low-quality trial14 (n42) compared open subacromial decompression and a physiotherapy program of exercise and education. At 6- and 12-month follow-up, there were no significant
differences between the groups for the number of participants who
reported success of treatment or of those reporting success and
partial success of treatment.
Another low-quality study15 (n125) reported no differences in
median Neer score between surgery and an exercise program at 3and 6-month follow-up. No differences in the median pain scores
(pain on activity, pain at rest, and pain at night) were reported
between surgery and nonoperative treatment. Therefore, these
low-quality trials found no evidence for the effectiveness of surgery (open or arthroscopic) compared with conservative treatment
for treating SIS in the short, mid, and long term.
1.2. Arthroscopic Versus Open Subacromial
Decompression
Systematic review. Five trials17-21 (n248) compared arthroscopic (ASD) versus open subacromial decompression
(OSD) for SIS. A low-quality trial17 (n32) found no differences between the groups on pain at rest at 3-, 6-, and 12-month
follow-up. Also, on pain with activity and the mean University
of California and Los Angeles (UCLA) shoulder rating scale
score no significant differences between ASD and OSD were
found at 3-,17 6-,17 12-,17-18 or 96-month17 follow-up.
1903
motion (ROM) were found at 1-year follow-up. In 2 lowquality trials17,19 no significant differences were found between ASD and OSD for muscle strength, at any evaluation
period.
Therefore, there is no evidence for the effectiveness of ASD
and OSD in the short, mid, and long term.
1.3. OSD: Neer Versus Modified Neer Technique
One low quality trial22 reported differences in abduction
between the Neer and modified Neer technique in OSD after 8
weeks, but this could not be verified from the data.
Table 4: Methodologic Quality Scores of the Included Cochrane Review of Coghlan et al11
Reference
Brox et al15
Haahr et al16
Husby et al17
Murphy et al24
Iversen et al20
Rahme et al14
Spangehl et al21
TJonck et al18
Ingvarrson et al22
Rubenthaler23
Sachs et al19
Allocation
Blinding
Randomization? Concealment? Patients?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
?
Blinding?
Outcome
Assessors?
?
?
?
Acceptable?
No. Lost
Intention-to-Treat
Score
Score
to Follow-up?
Analysis?
Maximum Study
NS
NS
NS
NS
?
NS
6
6
6
6
6
6
6
6
6
6
6
4
4
4
2
2
2
2
2
1
1
1
Overall
Validity
Quality
of the
Study
66
66
66
33
33
33
33
33
17
17
17
C
BC
C
C
C
C
C
C
C
C
C
Low
Low
Low
Low
Low
Low
Low
Low
Low
Low
Low
Abbreviations: , yes; -, no; ?, unclear; No. lost to follow-up, we defined this item positive if the percentage of lost to follow-up is 20% for
the short-term follow-up and 30% for the long-term follow-up; NS, not stated but participants completed within their surgical allocation;
Overall validity, A (low risk of bias), all criteria met; B (moderate risk of bias), 1 or more criteria partly met; C (high risk of bias), 1 or more
criteria not met.
1904
Postsurgery
NE
NE
NE
NE
NE
NE
NE
Short term
Long term
Pain pump vs control after ASD:
Long term
NE
NE
NE
NE
NE
NE
NE
NE
Abbreviations: , limited evidence found; , moderate evidence found; NE, no evidence found for effectiveness of the treatment: RCT(s)
available, but no differences between intervention and control groups were found.
*In favor of.
1905
1906
Embase
SIS shoulder impingement syndrome/OR ((shoulder/OR
shoulder) AND impingement) OR rotator cuff/OR rotator
cuff OR (subacrom* AND impingement) OR ((shoulder/OR
shoulder OR supraspinatus OR supra-spinatus OR infraspinatus OR infra-spinatus OR subscapularis OR sub-scapularis
OR teres minor) AND (tendinopathy OR tendovaginitis OR
tendovaginitis/or tendinit* OR tendonitis OR tendinitis/OR
tenosynovitis/OR tendinos* OR bursitis/)).
Therapy randomized controlled trial:it OR (randomized:
ti,ab AND controlled:ti,ab AND trial:ti,ab).
Systematic reviews (review/exp AND (medline:ti,ab OR
medlars:ti,ab OR embase:ti,ab OR pubmed:ti,ab) OR
scisearch:ti,ab OR psychlit:ti,ab OR psyclit:ti,ab OR psycinfo:
ti,ab OR pyschinfo:ti,ab OR cinahl:ti,ab OR hand search:
ti,ab OR manual search:ti,ab OR electric database:ti,ab OR
bibliographic database:ti,ab OR pooled analysis:ti,ab OR
pooled analyses:ti,ab OR pooling:ti,ab OR peto:ti,ab OR
dersimonian:ti,ab OR fixed effect:ti,ab OR mantel haenszel:ti,ab OR retracted article:ti,ab) OR (meta analysis/
exp OR meta analysis OR meta-analysis OR meta-analyses:ti,ab OR meta analyses:ti,ab OR systematic review:
ti,ab OR systematic overview:ti,ab OR quantitative
review:ti,ab OR quantitativ overview:ti,ab OR methodologic review:ti,ab OR methodologic overview:ti,ab OR integrative research review:ti,ab OR research integration:ti,ab
OR quantitative synthesis:ti,ab).
RCTs (controlled clinical trial/exp OR randomized controlled trial:ti OR controlled clinical trial:it OR randomization/OR double blind procedure/OR single blind procedure/OR crossover procedure/OR clinical trial:it OR
((clinical trial OR (singl* OR doubl* OR tripl*)) AND
(mask* OR blind*)) OR (Latin square design/OR latin
square OR latin-square) OR placebo/OR placebo* OR
random sample/OR comparative study:it OR evaluation study:it OR evaluation/exp OR follow up/exp OR
prospective study/OR control* OR prospectiv* OR volunteer*) NOT (animals/exp NOT humans/exp).
CINAHL
SIS (MH Shoulder impingement syndrome) or (MH rotator cuff)or rotator cuff or (subacrom* and impingement) or (((MH shoulder) or (MH shoulder joint) or
shoulder) and impingement) or (((MH shoulder) or (MH
shoulder joint) or shoulder or (MH shoulder pain) or
supraspinatus or supra-spinatus or infraspinatus or infraspinatus or subscapularis or sub-scapularis or teres minor) and ((MH Tendinitis) or (MH tenosynovitis) or
tend* or tenovaginitis or tendovaginitis)).
Reviews (MH Systematic Review).
Clinical trials (MH Clinical Trials).
PEDro
SIS Subacromial impingement syndrome, Rotator cuff syndrome, impingement syndrome Table a1, a2, a3.
Rahme et al14
SIS
Brox et al15
90
42
125
Placebo
Control/Comparison
SURGERY
Surgery (open or arthroscopic) vs. conservative treatment
Arthroscopic surgery
Conservative therapy (heat and
(n41)
cold packs, active training,
and strengthening exercise)
(n43)
Open surgery
(n21)
Arthroscopic surgery
(n45)
Supervised exercise
(n50)
Outcome Measures
Sex-adjusted difference in
median Neer score
Husby et al17
SIS
39
44
SIS
Husby et al17
SIS
39
Open surgery
(n17)
(n18)
(n16)
(n19)
(n15)
(n14)
(n17)
(n18)
(n15)
(n15)
Arthroscopic surgery
(n16)
(n19)
Open surgery
(n19)
Arthroscopic surgery
(n15)
(n 22)
Open surgery
(n17)
Pain
1907
Sachs et al19
Effect Size
Coghlan et al
SIS
Haahr et al16
SIS
Treatment
1908
Husby et al,
Tjonck et al18
Husby et al17
Iversen et al20
SIS
Spangehl et al21
SIS
Tjonck et al18
SIS
Tjonck et al18
SIS
Husby et al17
SIS
46
87
32 (36 shoulders)
32 (36 shoulders)
39
Treatment
Placebo
Control/Comparison
Outcome Measures
Effect Size
(n32)
(n31)
(n15)
Arthroscopic
(n21)
(n17)
Open surgery
(n20)
(n23)
(n27)
(n23)
(n24)
Arthroscopic
Open surgery
(n17)
Arthroscopic
(n17)
(n17)
(n17)
(n17)
Arthroscopic
(n11)
(n14)
(n15)
Open surgery
(n15)
(n15)
(n15)
(n33)
Open surgery
(n13)
(n17)
(n13)
(n17)
(n13)
(n18)
(n11)
(n13)
(n14)
(n13)
(n13)
(n17)
(n17)
(n18)
(n11)
(n13)
(n14)
(n17)
(n13)
(n17)
(n13)
(n18)
(n11)
(n13)
Treatment
Placebo
Control/Comparison
(n17)
(n13)
(n17)
(n13)
(n18)
Arthroscopic surgery
(n19)
Open surgery
(n 22)
Outcome Measures
Sachs et al19
SIS
44
Ingvarrson et al22
20
Rubenthaler et al23
38
Calcific tendinitis
48 (49 shoulders)
(n24)
Abbreviations: CI, confidence interval; FU, follow-up; ifo, in favor of; RR, relative risk; PRIM, aggregated pain and dysfunction score used in Project on Research and Intervention in
Monotonous work (range, 0 36); WMD, weighted mean difference; VAS, visual analog scale.
1909
(Murphy et al24)
SIS
Strength
Improvement (participant
evaluation, Moderate, or
complete improvement)
Effect Size
(n14)
1910
Author
Treatment
Placebo
Control/Comparison
ResultsStatistical
(P)
ResultsWords
SURGERY
Subacromial decompression vs radiofrequency-based plasma microtenotomy
Taverna et al25
ASD
Supraspinatus
tendinosis
(n30)
Everts et al26
SIS
RF-based arthroscopic
microtenotomy
(n30)
OSD only
(n20)
.470
Treatment vs comparison
Mean SD, 81 vs 81
.314
393 vs 394
.510
.137
162 vs 172
514 vs 5111
.416
.964
.794
.978
.001
no P given
.001
NS
.13
.05
.001
p0.05
Abbreviations: ADL, activities of daily living; ASD, arthroscopic subacromial decompression; FU, follow-up; ifo, in favor of; RF, radiofrequency; max, maximum; NS, not significant; Sig.,
significant; VAS, visual analog scale (range, 0 10).
Hultenheim
Klintberg et al27
POSTSURGERY
PG (active-assisted
ROM exercises on day 1 of
surgery (3/d) and
strengthening exercises after
6wk
Placebo
Control/Comparison
TG
(active- assisted dynamic
exercises for rotator
cuff after 6wk (3/d)
and strengthening
exercises after 8wk
post operative
(3/d)(n13)
ResultsStatistical
(P)
NS
(24mo)
No P given
No P given
No P given
No P given
NS
No P given
No P given
No P given
ROM: (degrees)
NS
Flexion:
.05
No P given
No P given
No P given
(n20)
Extension
(097)
3mo: 5 (078) vs 20 (075)
6mo: 14 (070) vs 12 (070)
12mo: 2 (035) vs 23 (084)
PG vs TG, median (range)
Baseline: 30 (972) vs 50 (095)
3mo: 0 (063) vs 10 (082)
6mo: 1 (063) vs 0 (030)
12mo: 0 (033) vs 5 (046)
PG vs TG, median (range)
Baseline: 150 (95170) vs 145 (90
180)
6wk: 160 (120180) vs 140 (85170)
3mo: 160 (140165) vs 150 (90170)
6mo: 165 (110180) vs 150 (85180)
12mo: 160 (140180) vs 150 (130180)
PG vs TG, median (range)
Baseline: 40 (2555) vs 40 (1575)
NS
(no P given)
.05
No P given
No P given
No P given
.05
No P given
.05
Shoulder function:
Constant score
(24mo)
1911
Abduction
NS
No P given
.05
No P given
No P given
NS
No P given
ResultsWords
SIS
Treatment
1912
Author
Hoe-Hansen et al28
SIS
Treatment
Placebo
Control/Comparison
ASD
plus
placebo
(n20)
ResultsStatistical
(P)
Treatment vs placebo:
6wk: 16/19 vs 9/19
NS
(No P given)
.05
NS
Active abduction
(degrees)
(No P given)
.05
NS
(No P given)
.05
NS
(No P given)
Jarvela et al29
SIS
UCLA score
(2y)
Constant score
(2y)
ResultsWords
.05
.137
.845
.831
.243
Abbreviations: FU, follow-up; ifo, in favor of; NS, not significant; PG, progressive group; TG, traditional group; VAS, visual analog scale (range, 0 10).
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1913