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REVIEW ARTICLE (META-ANALYSIS)
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results of the researchsupporting this article has or will confer a
benefit on the authors or on any organi-zati
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OSD open subacromial decompression
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Arcon with which the authors are associated.eprint requests to
Bionka M.A. Huisstede, PhD, Erasmus MC University
dical Center Rotterdam, Dept of Rehabilitation, Room H-016, PO
Box 2040, 3000Rotterdam, The Netherlands, e-mail:
[email protected]/11/9211-00260$36.00/0oi:10.1016/j.apmr.2011.06.006
PLG platelet-leukocyte gelRCT randomized controlled trialROM
range of motionSIS subacromial impingement syndromeUCLA University
of California at Los Angelesffectiveness of Surgical and
Poubacromial Impingement Syndkas Gebremariam, MD, Elaine M. Hay,
FRCP, MD, B
ABSTRACT. Gebremariam L, Hay EM, Koes BW, Huisst-BM.
Effectiveness of surgical and postsurgical interven-
ns for the subacromial impingement syndrome: a systematiciew.
Arch Phys Med Rehabil 2011;92:1900-13.
Objective: To provide an evidence-based overview of
theectiveness of surgical and postsurgical interventions for
theacromial impingement syndrome.
Data Sources: The Cochrane Library, PubMed, Embase,Dro, and
CINAHL were searched.Study Selection: Two reviewers independently
selected rele-t systematic reviews and randomized controlled
trials
CTs).Data Extraction: Two reviewers independently extracted
data
assessed the methodologic quality.Data Synthesis: If pooling of
data was not possible, a best-dence synthesis was used to summarize
the results.Results: One review and 5 RCTs reporting on various
sur-al techniques, and postsurgical interventions were
included.derate evidence was found in favor of adding
platelet-kocyte gel versus open subacromial decompression. Nodence
was found for the superiority of subacromial decom-ssion versus
conservative treatment in the short, mid, andg term or in favor of
1 surgical technique when compared
th another. Limited evidence was found in favor of earlyivation
after arthroscopic decompression in the short andg term.
Conclusions: This review shows that there is no evidence
thatgical treatment is superior to conservative treatment or
that1ticular surgical technique is superior to another. Because
of
ssibly lower risks for complications, conservative treatmenty be
preferred. When choosing for surgery, arthroscopicompression may be
preferred because of the less invasiveracter of the procedure.
Key Words: General surgery; Rehabilitation; Shoulder;oulder
impingement syndrome; Treatment outcome. 2011 by the American
Congress of Rehabilitationdicine
HE SUBACROMIAL IMPINGEMENT syndrome (SIS)includes a number of
pathologic entities: rotator cuff syn-
me, tendonitis, and bursitis in the shoulder.1 SIS occursen the
soft tissues of the glenohumeral joint between theacoacromial arch
and the humeral tuberosity are com-
rom the Departments of General Practice (Gebremariam, Koes,
Huisstede); andabilitation Medicine (Huisstede), Erasmus MC
University Medical Centerterdam, Rotterdam, The Netherlands; the
Arthritis Research Campaign National
ary Care Centre, Keele University, Keele, United Kingdom (Hay).h
Phys Med Rehabil Vol 92, November 2011urgical Interventions for
theme: A Systematic ReviewW. Koes, PhD, Bionka M. Huisstede,
PhD
ssed, disturbing the normative sliding mechanism whenvating the
arm. Patients visiting their general practitionerth Complaints of
the Arm, Neck and/or Shoulder (CANS),1t is, nontraumatic
musculoskeletal complaints of the upperremity not caused by any
systemic disease, frequently reportulder complaints2; 33% of those
with CANS are diagnosed
th SIS.3Work-related factors associated with the occurrence of
SISlude handling of loads frequently or with high force,
highlyetitive work, hand-arm vibration, work above shoulderel, and
high job demands (high work pressure and highotional
demands).4Affected patients complain of anterolateral shoulder
paint is worsened by active lifting of the arm into the impinge-nt
arc (60120 of shoulder abduction).5 Also pain at nightfrequently
reported, exacerbated by lying on the involvedulder, or sleeping
with the arm overhead.6
Various physical tests for diagnosing SIS have been de-ibed, but
it remains difficult for physicians to differentiateween the
different types of tendonitis and bursitis around theulder.1
According to Park et al,7 the best combination of
ysical tests to diagnose SIS is a positive
Hawkins-Kennedypingement sign (pain and resulting facial expression
whenlying forward flexion of the shoulder to 90 and internal
ation), a positive painful arc sign, and weakness in
externalation with the arm at the side. However, although
physicalts are important, they may not be sufficient for
appropriategnosis, because most tests for SIS have greater
sensitivityn specificity.8 Therefore, in addition to the patient
history,ysical examination findings, and specific impingement
testneuvers (eg, Neer and Hawkins-Kennedy), radiologic eval-ion
with ultrasound and magnetic resonance imaging isommended.8Current
accepted approaches to treat SIS include both con-vative and
surgical management.9 Having clinical symptomsover 1 year10 and the
severity of symptoms were reported
be prognostic factors for a negative outcome on
conservativeervention.9,10 When conservative approach fails,
surgicalatment is considered.Currently there is no review that
solely concentrates on theectiveness of interventions for SIS only.
One Cochraneiew11 concentrates on surgical interventions to treat
rotatorf disease. Since the publication of the Cochrane review,
new
List of Abbreviations
ASD arthroscopic subacromial decompressionASES American Shoulder
and Elbow SurgeonsCANS Complaints of the Arm, Neck and/or
Shoulder
-
RCconsamtheparforbasenteff
Se
conCotosyninc
Inc
forSISasincevaporep
Stu
inctitlseame(BCa
SysRCsys
describes all RCTs concerning an intervention that has not
yetbeen described in a systematic review.
Da
datstuouinandlon
Me
reveacal.waproers
assloghavinc
Da
hetThthadenbetheanweof
Stu
CovieandCoincefftria
Table 1: Methodologic Quality Assessment: Sources of Risk
Bias
Items Risk of Bias1.2.3.4.5.6.7.
8.
9.
10.11.12.
Strth
Mow
Limw
Coi
Nob
1901SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME,
GebremariamTs have been published, and we wondered whether
theclusions made in the Cochrane review would remain thee or would
need modification. In order to further optimizequality of care for
patients with SIS given by clinicians andamedical staff, an
overview regarding evidence-based in-mation is needed that can
support developing evidence-ed treatment protocols and guidelines.
The aim of the pres-study is to provide an evidence-based overview
of the
ectiveness of surgical and postsurgical interventions for
SIS.
METHOD
arch StrategyTo identify relevant systematic reviews and
randomizedtrolled trials (RCTs) on SIS, a search was performed in
the
chrane Library, PubMed, Embase, PEDro, and CINAHL upFebruary
2009. Key words such as shoulder impingementdrome and rotator cuff
impingement and interventions wereluded in the literature search
(appendix 1).lusion Criteria
Systematic reviews and/or RCTs were considered eligibleinclusion
if: (1) the study included patients with SIS, (2)was not caused by
an acute trauma or any systemic disease
described in the definition of CANS, (3) an intervention,luding
a postsurgical intervention, for treating SIS wasluated, (4)
results on pain, function, or recovery were re-
rted, and (5) a follow-up period of at least 2 weeks wasorted.
There were no language restrictions.
dy SelectionTwo reviewers (L.G. and B.H.) independently applied
thelusion criteria to select potential relevant studies from thee
and abstracts of the references retrieved by the literaturerch. A
consensus method was used to solve any disagree-nts concerning
inclusion of studies, and a third reviewer.K.) was consulted if
disagreement persisted.tegorization of the Relevant
LiteratureRelevant literature is categorized under 3 different
headers:tematic reviews describes all (Cochrane) reviews; RecentTs
contains all RCTs published after the search date of thetematic
review on the same intervention; Additional RCTs
Was the method of randomization adequate?Was the treatment
allocation concealed?Was the patient blinded to the
intervention?Was the care provider blinded to the intervention?Was
the outcome assessor blinded to the intervention?Was the dropout
rate described and acceptable?Were all randomized participants
analyzed in the group towhich they were allocated?Are reports of
the study free of suggestion of selectiveoutcome reporting?Were the
groups similar at baseline regarding the mostimportant prognostic
indicators?Were cointerventions avoided or similar?Was the
compliance acceptable in all groups?Was the timing of the outcome
assessment similar in allgroups?ta ExtractionTwo authors (L.G. and
B.H.) independently extracted thea of the included studies.
Information was collected on thedy population, interventions, and
outcome measures. Thetcome evaluation was determined as short term
if it occurredless than 3 months (after baseline), middle term
between 4
6 months, and long term when the follow-up period wasger than 6
months.
thodologic Quality AssessmentTo identify potential risks of bias
of the included RCTs, 2iewers independently assessed the
methodologic quality ofh RCT, using the 12 quality criteria (table
1) of Furlan et
12 Each item was scored as yes, no, or unclear. High qualitys
defined as a yes score of 50% or more. A consensuscedure was used
to solve disagreement between the review-.In a (Cochrane) review
the use of a methodologic qualityessment is a standard procedure.
We describe the methodo-ic quality scale or criteria that were used
in the review, ande used their definitions of high and low quality
of theluded studies.
ta SynthesisA quantitative analysis of the studies was not
possible due toerogeneneity of the outcome measures or study
population.erefore, we summarized the results using a rating
systemt consisted of 5 levels of scientific evidence (ie,
best-evi-ce synthesis)13 (table 2). An article was included in
the
st-evidence synthesis if a comparison was made betweenstudy
groups (treatment vs placebo/control/treatment),
d the level of significance was reported. The study resultsre
labeled significant if it reported significant results on 1the 3
outcomes.
RESULTS
dy CharacteristicsThe initial literature search identified 5
reviews via thechrane Library, 5 reviews/215 RCTs via PubMed, 21
re-ws/193 RCTs via Embase, 141 reviews/RCTs via CINAHL,
0 reviews/13 RCTs via PEDro were identified. Finally, 1chrane
review and 5 RCTs (all found in PubMed) wereluded. The Cochrane
review of Coghlan et al,11 studying theectiveness of surgery for
rotator cuff disease, included 14ls; 11 (n611) of these studies
reported on SIS (including
Table 2: Levels of Evidence
ong evidence: consistent (ie, when 75% of the trials reporthe
same findings), positive (significant) findings within
multipleigher quality RCTs.derate evidence: consistent, positive
(significant) findingsithin multiple lower quality RCTs and/or 1
high-quality RCT.ited evidence for effectiveness: positive
(significant) findingsithin 1 low-quality RCT.
nflicting evidence: provided by conflicting (significant)
findingsn the RCTs (75% of the studies reported consistent
findings).evidence: RCT(s) available, but no (significant)
differencesetween the intervention and control groups were
reported.Arch Phys Med Rehabil Vol 92, November 2011
-
3 ssho
Me
qu
ThThnotioRCofmeme
Efto
1.
1.1Ve
Soptrenosiomethetredytiober(comtiodifreppar
meand(pabetlowgerfor
1.2De
Sthr(Oencfolofscofou
Tab
le3:
Met
ho
do
log
icQ
ual
ity
Sco
res
of
the
Incl
ud
edR
ecen
tan
dA
dd
itio
nal
RC
Ts
Referen
ceAdeq
uate
Ran
domization?
Allo
cation
Conce
almen
t?Blin
ding?
Patients?
Blin
ding?
Careg
iver?
Blin
ding?
Outcome
Asses
sors?
Inco
mplete
Outcome
Data
Addressed
?Dropouts?
Inco
mplete
Outcome
Data?
ITT
Analys
is?
Free
of
Sugges
tions
ofSelec
tive
Outcome
Rep
orting?
Sim
ilarity
of
Bas
eline
Charac
teristics?
Cointerven
tions
Avo
ided
or
Sim
ilar?
Complia
nce
Accep
table
inallGroups?
Tim
ingof
the
Outcome
Asses
smen
tSim
ilar?
Max
imum
Sco
reSc
Stu
Eve
rts
etal
26
?
NA
11
Tav
erna
etal
25
?
?
?
?
NA
11
Hulten
heim
Klin
tberg
etal
27
??
12Ja
rvela
etal
29
?
?
?
12Hoe-Han
sen
and
Norlin
28
??
?
??
?
12
Abbreviations:,ye
s;-,no;?,
unclea
r/unsu
re;ITT,intention-to-treat;NA,notap
plic
able
(inanontimeinterven
tion,eg
,su
rgery,
complia
nce
isnotan
issu
e).
1902
Arch Phys Med Rehabil Vol 92, November 2011tudying postsurgical
interventions. Appendices 2, 3, and 4w characteristics of the
included studies.
thodologic QualityTables 3 and 4 present the results of the
methodologicality assessment.Two of the 5 included RCTs were
classified as high quality.e 3 low-quality RCTs scored 33% to 42%
of the total score.e most prevalent methodologic flaws were: (1)
care providert blinded (75%) (as expected in surgery) and (2) no
inten-n-to-treat analysis (75%) was applied by the authors of
theTs. According to the authors of the Cochrane review,11 10the 11
RCTs had a high risk of bias, and 1 RCT had adium to high risk of
bias; 6 items were used to score thethodologic quality of these
studies.
fectiveness of Surgical and Postsurgical InterventionsTreat SISA
complete overview of the evidence is presented in table 5.
Effectiveness of Surgery
. Arthroscopic or Open Subacromial Decompressionrsus
Conservative Treatmentystematic review. Three trials (n258)
compared either
en14 or arthroscopic15,16 surgery with active
nonoperativeatment. The low-quality study of Haahr et al16 (n90)
founddifferences between arthroscopic subacromial decompres-n and a
graded physiotherapy strengthening program on thean change in
Constant score at 3, 6, and 12 months. Fur-rmore, there were no
significant differences between the 2atment groups for the PRIM
score (aggregated pain andsfunction score used in Projects on
Research and Interven-n in Monotonous work) at 12 months, or
between the num-
of participants with a good or excellent Constant score80) at 12
months.A low-quality trial14 (n42) compared open subacromial
de-
pression and a physiotherapy program of exercise and educa-n. At
6- and 12-month follow-up, there were no significantferences
between the groups for the number of participants whoorted success
of treatment or of those reporting success andtial success of
treatment.Another low-quality study15 (n125) reported no
differences indian Neer score between surgery and an exercise
program at 3-6-month follow-up. No differences in the median pain
scores
in on activity, pain at rest, and pain at night) were
reportedween surgery and nonoperative treatment. Therefore,
these-quality trials found no evidence for the effectiveness of
sur-y (open or arthroscopic) compared with conservative
treatmenttreating SIS in the short, mid, and long term.
. Arthroscopic Versus Open Subacromialcompressionystematic
review. Five trials17-21 (n248) compared ar-
oscopic (ASD) versus open subacromial decompressionSD) for SIS.
A low-quality trial17 (n32) found no differ-es between the groups
on pain at rest at 3-, 6-, and 12-month
low-up. Also, on pain with activity and the mean
UniversityCalifornia and Los Angeles (UCLA) shoulder rating scalere
no significant differences between ASD and OSD werend at 3-,17
6-,17 12-,17-18 or 96-month17 follow-up.calcific tendinitis) and
met our inclusion criteria. Figure 1shows the process of
identifying the relevant articles. Further-more, we included 5
additional RCTs: 2 studying surgery andore d
y%
982
655
542
542
433
SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME,
Gebremariam
-
forlowonand
difipascoshoFu
moqutwpe
Figsea
BrHaHuMIveRaSpTInRuSa
AbtheOvcrit
1903SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME,
GebremariamA low-quality trial19 (n44) reported equivalent pain
scoresboth groups at time points up to 1 year. Also, in
another-quality trial20 (n46) there were no significant
differencesthe mean UCLA shoulder rating scale score between ASDOSD
(follow-up time unclear).
Two low-quality trials20,21 (n97) reported no
significantferences between the groups on the proportion of
partic-nts with a good or excellent UCLA shoulder rating scalere.
The Constant score, measured in a low-quality trial,18wed no
significant difference between ASD and OSD.
rther, no differences between both groups on range of
1. Flowchart of the literaturerch.
Table 4: Methodologic Quality Scores of the
Reference Randomization?Allocation
Concealment?BlindingPatients?
Blinding?OutcomeAssessors?
ox et al15 ? ahr et al16 sby et al17 ? urphy et al24 ?rsen et
al20 ? ? hme et al14 ? angehl et al21 ? ? Jonck et al18 ? ? ?
?gvarrson et al22 ? ? ? ?benthaler23 ? ? ? ?chs et al19 ? ?
breviations: , yes; -, no; ?, unclear; No. lost to follow-up, we
defineshort-term follow-up and 30% for the long-term follow-up;
NS,
erall validity, A (low risk of bias), all criteria met; B
(moderate riskeria not met.tion (ROM) were found at 1-year
follow-up. In 2 low-ality trials17,19 no significant differences
were found be-een ASD and OSD for muscle strength, at any
evaluationriod.Therefore, there is no evidence for the
effectiveness of ASD
OSD in the short, mid, and long term.
. OSD: Neer Versus Modified Neer TechniqueOne low quality
trial22 reported differences in abductionween the Neer and modified
Neer technique in OSD after 8eks, but this could not be verified
from the data.
ed Cochrane Review of Coghlan et al11
ceptable?o. Lostollow-up?
Intention-to-TreatAnalysis?
ScoreMaximum
ScoreStudy %
OverallValidity
Qualityof theStudy
6 4 66 C Low 6 4 66 BC Low NS 6 4 66 C Low? NS 6 2 33 C Low 6 2
33 C Low 6 2 33 C Low NS 6 2 33 C Low 6 2 33 C Low NS 6 1 17 C Low
? 6 1 17 C Low NS 6 1 17 C Low
is item positive if the percentage of lost to follow-up is 20%
fortated but participants completed within their surgical
allocation;s), 1 or more criteria partly met; C (high risk of
bias), 1 or moreand
1.3
betwe
Includ
AcN
to F
d thnot sof biaArch Phys Med Rehabil Vol 92, November 2011
-
mo
1.4Ca
SAStenrepat 1iotcomcal
1.5S
2 dNoscadifwasco95ferandtivin
Table 5: CANS: Evidence for Effectiveness of Surgical and
Postsurgical Interventions for Subacromial Impingement Syndrome
Surgery vs Conservative Postsurgery
EEE
EEE
EE
E
E
EEE
Abava*In
1904 SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME,
Gebremariam
ArcThere is no evidence for effectiveness of the Neer versus
thedified Neer technique in OSD.
. ASD Versus OSD to Remove Calcium Deposit inlcific
Tendonitisystematic review. A low-quality study23 (n38)
compared
D and OSD to remove calcium deposits in patients with
calcificdonitis. No significant differences between the groups
wereorted on pain relief and subjective ratings of shoulder
function6-month follow-up or average duration of postoperative
phys-
herapy. There is no evidence for the effectiveness of ASDpared
with OSD to remove calcium deposits in patients with
cific tendonitis in the short and mid term.
. Electrocautery Versus Holium Laser in ASDystematic review. A
low-quality study24 (n49) comparedifferent ASD techniques: holium
laser versus electrocautery.significant results were found on the
UCLA shoulder rating
le scores at 3-, 6-, and 12-month follow-up. A small
significantference between the groups in favor of the
electrocautery groups found in the American Shoulder and Elbow
Surgeons (ASES)re at 6-month follow-up (weighted mean difference,
8.00;
% confidence interval, 15.62 to 0.38). No significant dif-ences
between the groups on the ASES score were found at 3-
12-month follow-up. There is limited evidence for the
effec-eness of electrocautery compared with the holium laser in
ASDthe short and mid term and no evidence for the long term.
ASD or OSD vs conservative:Short term NMid term NLong term N
ASD vs OSD: ASD vs OSD:Short term NMid term NLong term N
ASD vs OSD for removal of calcium deposits:Short term NMid term
N
OSD: Neer vs modified Neer technique:Short term N
ASD: ASD using electrocautery* vs using a Holium laser:Short
termMid termLong term N
ASD vs radiofrequency-based plasma microtenotomy:Short term NMid
term NLong term N
In surgery: PLG* vs control in OSDShort term
breviations: , limited evidence found; , moderate evidence
fouilable, but no differences between intervention and control
groupsfavor of.h Phys Med Rehabil Vol 92, November 2011. ASD Versus
Radiofrequency-Based Plasmacrotenotomyecent RCT. A high-quality
study25 (n60) examined ASD
sus radiofrequency-based plasma microtenotomy. After 3, 6,12
months, no significant differences were found between the
ups for the visual analog scale, ASES, UCLA shoulder ratingle,
and the Constant score. Therefore, there is no evidence
foreffectiveness of ASD versus radiofrequency-based plasma
crotenotomy to treat SIS in the short, mid, and long term.
. Platelet-Leukocyte Gel as Add-On Therapy in OSDAdditional RCT.
A high-quality RCT26 (n40) studied theect of platelet-leukocyte gel
(PLG) on postoperative recov-of patients undergoing OSD. Only
patients in the treatmentup were injected with PLG. Six weeks
postoperatively, theG group showed a significant (P.001) decrease
in pain
pared with the control group (no exact data given).
Further,ignificantly better shoulder index score (P.001) was
foundfavor of the PLG group compared with the controls ateeks
follow-up (no exact data given). There were no sig-cant differences
(P.13) on shoulder instability scores be-
een the 2 groups at 6-weeks follow-up. The PLG groupwed
significantly (P.05) more activities in daily livingn the control
group and showed significantly (P.001)proved ROM at 12-weeks
follow-up (no exact data given).erefore, there is moderate evidence
for the effectiveness of
Ketoprofen* after ASD vs control:Short term Long term NE
Early activation* vs protective activationphysiotherapy after
ASD
Short term Long term
Pain pump vs control after ASD:Long term NE
E, no evidence found for effectiveness of the treatment:
RCT(s)found.1.6Mi
Rverandgroscathemi
1.7
efferygroPLcoma sin6-wnifitwshothaimTh
nd; Nwere
-
PLG on postoperative recovery of patients undergoing OSD inthe
short-term.
2.
2.1Af
Aenthadexeperprodaycisshores(Pbetthe(Pupthelon
2.2A
fen(nofthepronififenforThatketlon
2.3A
oftheuponCo
a ppat
meevipretrecona swestucominwi
stated that if an intention-to-treat analysis was conducted,
theeffectiveness of surgery should be favorable.14
In general, surgical interventions for treating
subacromialimhigexeintmafurtw
persupThtivrecfousur
fouandAS
meaftterthesurinfl
Stu
logqurepmetio
diftervalodlowquthaatconIfclascohigconint
stuincdif
treticBetioWh
1905SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME,
GebremariamEffectiveness of Postsurgery Treatments
. Early Activation Versus Protective Physiotherapyter ASD
dditional RCT. A low-quality RCT27 compared 2
differ-physiotherapy protocols in patients (n33) with SIS whoASD. A
traditional group received active assisted dynamic
rcises for the rotator cuff 6 weeks after operation (3 timesday)
and strengthening exercises 8 weeks after operation. Agressive
group received active assisted ROM exercises 1after operation (3
times per day) and strengthening exer-
es 6 weeks after operation (3 times per day). Both groupswed
significant improvements in pain during activity and att at
12-month follow-up. There were also significant
.05) improvements in ROM in extension and abductionween the
groups at 3- and 12-month follow-up in favor ofprogressive group.
The Constant score was significantly0.05) higher in the progressive
group at 6-weeks follow-
, but not at 3-month follow-up. There is limited evidence
foreffectiveness of progressive physiotherapy in the short andg
term compared with traditional physiotherapy.
. Ketoprofen Versus Placebo After ASDdditional RCT. A
low-quality study28 compared ketopro-200mg once daily for 6 weeks
(n21) with the placebo20) in patients who had ASD. After 6 weeks,
the number
patients showing mild or no pain was significantly higher
inketoprofen group compared with the placebo group (keto-fen: 16 of
19 vs placebo: 9 of 19, P.005). Further, sig-cant results (P.05)
were reported in favor of the ketopro-group on the UCLA shoulder
rating scale score, active
ward flexion, and active abduction at 6-weeks follow-up.ese
significant differences on the short term did not sustain2-years
follow-up. Therefore, there is limited evidence foroprofen after
ASD in the short-term and no evidence in theg-term.
. Pain Pump After ASDdditional RCT. A low-quality RCT29 compared
the use
a pain pump with 0.375% ropivacaine after ASD as add-onrapy with
a rehabilitation group (n50). At 2-years follow-, no significant
differences were found between the groupsthe UCLA shoulder rating
scale score (P.845) and on thenstant score (P.243).There is no
evidence in the long term for the effectiveness ofain pump as
add-on therapy to rehabilitation after ASD inients with SIS.
DISCUSSIONIn general, patients failing to respond to
conservative treat-nts are considered for surgery. In the present
review nodence was found for the superiority of subacromial
decom-ssion (arthroscopic or open) compared with conservativeatment
in the short, mid, and long term. However, ourclusion is based on
only 3 low-quality studies that includedmall number of patients.
Although no significant resultsre found between surgery and
conservative treatment, 1dy16 found better within-group results
(ie, significant out-
e when the pre- and posttreatment results were compared)the
conservative group, and another study15 found betterthin-group
results in the surgery group. The third studypingement are
associated with more complications andher costs than conservative
treatment.15 One review foundrcise therapy to be 1 of the most
effective conservative
ervention to treat SIS in the short and mid term (Gebre-riam,
unpublished data, 2011). More studies are needed tother elucidate
the evidence for differences in outcome be-een surgery and
conservative interventions.If patients are treated surgically,
either OSD or ASD can beformed. In the present review no evidence
was found for theeriority of ASD or OSD in the short, mid, and long
term.
is conclusion is based on 5 low-quality studies with rela-ely
small groups of patients. ASD tends to give a fasterovery due to
its less invasive nature.19,30 No trials werend that focused on
defining an optimal timing strategy forgery; future studies should
focus on this important topic.For within-surgery techniques,
moderate evidence wasnd for the effectiveness of PLG as add-on
therapy to OSD,
limited evidence was found for using electrocautery inD versus
using the holium laser.
Only a few RCTs were found studying postsurgical manage-nt.
Limited evidence was found in favor of early activationer ASD
versus protective activation in the short and longm, and for
ketoprofen after ASD in the short term (although
latter effect did not sustain in the long term). Thus, ifgery is
required, it seems that postsurgical intervention canuence the
outcome of surgery.
dy LimitationsThis review has some limitations. In general, the
methodo-ic quality of the included studies was low; only 2
high-
ality RCTs were found. This may be a result of inadequateorting
in the studies. Four of the 5 included RCTs failed tontion
allocation concealment and whether or not cointerven-ns were
avoided or similar.The included Cochrane review of Coghlan et al11
usedferent methodologic quality criteria compared with our cri-ia
based on Furlan et al.12 Because of the high credibility andidity
of Cochrane reviews, we decided to apply the meth-ologic quality
criteria and definitions of high-quality and-quality studies used
in a Cochrane review. However, the
ality criteria of the Cochrane reviews11 included fewer itemsn
our 12 quality criteria, and high quality was not defined asleast
50% of the items were scored positive. This couldtribute to bias in
the outcome of evidence and conclusions.we would we have used our
definition that a study isssified as high quality if at least 50%
of the items werered positive, 3 of the 11 RCTs would have been
classified ash-quality studies (see table 3). However, in this
case, ourclusions regarding the evidence for effectiveness of
the
erventions would remain similar.Further, it should be addressed
that the power of somedies was low, because only a small number of
patients wereluded; maybe because of this, no statistically
significantferences between the groups were found.
CONCLUSIONSThis review shows that there is no evidence that
surgicalatment is superior to conservative treatment or that 1
par-ular surgical technique is superior to another to treat
SIS.cause of lower costs and possibly lower risk of complica-ns,
conservative treatment may be preferred to surgery.en choosing
surgery, arthroscopic decompression may beArch Phys Med Rehabil Vol
92, November 2011
-
preferred because of the faster recovery of ROM and theminimally
invasive character of the procedure. Furthermore,early activation
postsurgery might have positive results butadditional studies are
required to confirm this statement.
Acknowledgement: We thank M.S. Randsdorp (MR), MD, forher
participation in the quality assessment.
APPENDIX 1: SEARCH STRATEGY
Pu
SIS
Th
Sy
RC
EmbaseSIS shoulder impingement syndrome/OR ((shoulder/OR
shoulder) AND impingement) OR rotator cuff/OR rotatorcuff OR
(subacrom* AND impingement) OR ((shoulder/ORshoulder OR
supraspinatus OR supra-spinatus OR infraspina-tus OR infra-spinatus
OR subscapularis OR sub-scapularisOR teres minor) AND (tendinopathy
OR tendovaginitis ORtendovaginitis/or tendinit* OR tendonitis OR
tendinitis/ORtenosynovitis/OR tendinos* OR bursitis/)).
Therapy randomized controlled trial:it OR (randomized:Sy
RC
CISIS
ReClPESIS
1906 SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME,
Gebremariam
ArcbMed
shoulder impingement syndrome[mh] OR rotatorcuff[mh] OR rotator
cuff OR (subacrom* AND im-pingement) OR (shoulder AND impingement)
OR ((shoul-der OR shoulder pain[mh] OR supraspinatus OR
supra-spinatus OR infraspinatus OR infra-spinatus ORsubscapularis
OR sub-scapularis OR teres minor) AND(tendinopathy[mh:noexp] OR
tenovaginitis OR tendovagi-nitis OR tendinit* OR tendonitis OR
tenosynovitis ORtendinos* OR bursitis[mh:noexp])).
erapy (randomized controlled trial[Publication Type]
OR(randomized[Title/Abstract] AND controlled[Title/Ab-stract] AND
trial[Title/Abstract])).
stematic reviews ((meta-analysis [pt] OR meta-analysis[tw] OR
metanalysis [tw]) OR ((review [pt] OR guideline[pt] OR consensus
[ti] OR guideline* [ti] OR literature [ti]OR overview [ti] OR
review [ti]) AND ((Cochrane [tw]OR Medline [tw] OR CINAHL [tw] OR
(National [tw]AND Library [tw])) OR (handsearch* [tw] OR
search*[tw] OR searching [tw]) AND (hand [tw] OR manual [tw]OR
electronic [tw] OR bibliographi* [tw] OR database*OR (Cochrane [tw]
OR Medline [tw] OR CINAHL [tw]OR (National [tw] AND Library
[tw]))))) OR ((synthesis[ti] OR overview [ti] OR review [ti] OR
survey [ti]) AND(systematic [ti] OR critical [ti] OR methodologic
[ti] ORquantitative [ti] OR qualitative [ti] OR literature [ti]
ORevidence [ti] OR evidence-based [ti]))) BUTNOT (case*[ti] OR
report [ti] OR editorial [pt] OR comment [pt] ORletter [pt]).Ts
(randomized controlled trial [pt] OR controlled clini-cal trial
[pt] OR randomized controlled trials [mh] ORrandom allocation [mh]
OR double-blind method [mh] ORsingle-blind method [mh] OR clinical
trial [pt] OR clinicaltrials [mh] OR clinical trial [tw] OR
((singl* [tw] ORdoubl* [tw] OR trebl* [tw] OR tripl* [tw]) AND
(mask*[tw] OR blind* [tw])) OR latin square [tw] OR placebos[mh] OR
placebo* [tw] OR random* [tw] OR researchdesign [mh:noexp] OR
comparative study [mh] OR eval-uation studies [mh] OR follow-up
studies [mh] OR pro-spective studies [mh] OR cross-over studies
[mh] OR con-trol* [tw] OR prospectiv* [tw] OR volunteer* [tw])
NOT(animal [mh] NOT human [mh]).h Phys Med Rehabil Vol 92, November
2011ti,ab AND controlled:ti,ab AND trial:ti,ab).stematic reviews
(review/exp AND (medline:ti,ab OR
medlars:ti,ab OR embase:ti,ab OR pubmed:ti,ab) ORscisearch: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 ORbibliographic
database:ti,ab OR pooled analysis:ti,ab ORpooled analyses:ti,ab OR
pooling:ti,ab OR peto:ti,ab ORdersimonian:ti,ab OR fixed
effect:ti,ab OR mantel haen-szel:ti,ab OR retracted article:ti,ab)
OR (meta analysis/exp OR meta analysis OR meta-analysis OR
meta-anal-yses:ti,ab OR meta analyses:ti,ab OR systematic
review:ti,ab OR systematic overview:ti,ab OR
quantitativereview:ti,ab OR quantitativ overview:ti,ab OR
methodo-logic review:ti,ab OR methodologic overview:ti,ab OR
in-tegrative research review:ti,ab OR research integration:ti,abOR
quantitative synthesis:ti,ab).Ts (controlled clinical trial/exp OR
randomized con-trolled trial:ti OR controlled clinical trial:it OR
random-ization/OR double blind procedure/OR single blind
pro-cedure/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 latinsquare OR latin-square) OR placebo/OR
placebo* ORrandom sample/OR comparative study:it OR evalua-tion
study:it OR evaluation/exp OR follow up/exp ORprospective study/OR
control* OR prospectiv* OR vol-unteer*) NOT (animals/exp NOT
humans/exp).
NAHL (MH Shoulder impingement syndrome) or (MH ro-
tator cuff)or rotator cuff or (subacrom* and impinge-ment) or
(((MH shoulder) or (MH shoulder joint) orshoulder) and impingement)
or (((MH shoulder) or (MHshoulder joint) or shoulder or (MH
shoulder pain) orsupraspinatus or supra-spinatus or infraspinatus
or infra-spinatus or subscapularis or sub-scapularis or teres
mi-nor) and ((MH Tendinitis) or (MH tenosynovitis) ortend* or
tenovaginitis or tendovaginitis)).
views (MH Systematic Review).inical trials (MH Clinical
Trials).Dro
Subacromial impingement syndrome, Rotator cuff syn-drome,
impingement syndrome Table a1, a2, a3.
-
Au
CoghlanSISHaahr eSIS
RahmeSIS
Brox et
Husby eSIS
Sachs e
SISHusby eSIS
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2011APPENDIX 2: DATA EXTRACTIONSYSTEMATIC REVIEWS
thor Total No. of Patients Treatment Placebo Control/Comparison
Outcome Measures Effect Size
et al11 SURGERYSurgery (open or arthroscopic) vs. conservative
treatment
t al16 90 Arthroscopic surgery(n41)
Conservative therapy (heat andcold packs, active training,and
strengthening exercise)
(n43)
Mean change in Constantscore
3mo: WMD, 4.60 (95% CI, 12.48 to 3.28)6mo: WMD, 1.40 (95% CI,
10.43 to 7.63)12mo: WMD, 4.50 (95% CI, 13.73 to 4.73)
Mean PRIM score (12mo) WMD, 0.0 (95% CI, 4.77 to 4.77)Constant
score 80 (12mo) RR1.05 (95% CI, 0.49 to 2.25)
et al14 42 Open surgery Conservative therapy (exerciseand
education)
Success (reduction of 100%pain score from baseline)
6mo: RR1.07 (95% CI, 0.34 to 3.40)12mo RR1.89 (95% CI, 0.81 to
4.41)
(n21) (n18) Success and partial success(reduction of 100%
painscore or reduction 51-99%pain score from baseline)
6 mo: RR 1.71 (95% CI, 0.81 to 3.63)12 mo: RR 1.25 (95% CI, 0.80
to 1.93)
al15 125 Arthroscopic surgery(n45)
Supervised exercise(n50)
Neer score Baseline: arthroscopic: 64 (median) vsexercise:
67.5
3mo: arthroscopic: 84 vs exercise: 746mo: arthroscopic: 87 vs
exercise: 86
Sex-adjusted difference inmedian Neer score
3mo: 3.6 (95% CI, 0.2 to 7.4)6mo: 2.0 (95 % CI, 1.4 to 5.4)
Arthroscopic vs open surgeryt al17 39 Arthroscopic Open surgery
Mean pain at rest 3mo: WMD, 1.00 (95% CI, 13.59 to 15.59)
(n15) (n17) (VAS 0100) 6mo: WMD, 8.60 (95% CI, 17.40 to
0.20)(n14) (n18) 12mo: WMD, 2.70 (95% CI, 7.82 to 2.42)(n15) (n16)
96mo: not estimable(n15) (n19) Mean pain during activity (VAS
0100)3mo: WMD, 0.0 (95% CI, 19.77 to 19.77)
(n15) (n17) 6mo: WMD, 12.00 (95% CI, 30.46 to 6.46)(n14) (n18)
12mo: WMD, 3.00 (95% CI, 20.67 to
14.67)(n15) (n16) 96mo: WMD, 0.0 (95% CI, 12.86 to 12.86)(n15)
(n19)
t al19 44 Arthroscopic surgery Open surgery Pain Equivalent pain
scores at 12, 26, and 52wk(no data given)
(n19) (n 22)t al17 39 Arthroscopic surgery Open surgery Mean
UCLA score 3mo: WMD, 0.0 (95% CI, 4.53 to 4.53)
(n15) (n17) 6mo: WMD, 1.00 (95% CI, 3.96 to 5.96)
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2011APPENDIX 2: DATA EXTRACTIONSYSTEMATIC REVIEWS (Contd)Author
Total No. of Patients Treatment Placebo Control/Comparison Outcome
Measures Effect Size
usby et al,17 (n32) (n31) Mean UCLA score 12mo: WMD, 1.61 (95%
CI, 1.22 to 4.44)onck et al18
usby et al17 (n15) (n17) Mean UCLA score 96mo: WMD, 0.0 (95% CI,
4.00 to 4.00)ersen et al20 46 Arthroscopic Open surgery Mean UCLA
score WMD, 0.40 (95% CI, 3.43 to 4.14)IS (n21) (n20) (FU time
unclear) Good or
excellentRR0.94 (95% CI, 0.65 to 1.35)
(n23) (n23) UCLA score (FU time unclear)pangehl et al21 87 (n27)
(n24) Good or excellent RR1.00 (95% CI, 0.68 to 1.48)IS UCLA score
(FU time unclear)onck et al18
IS32 (36 shoulders) Arthroscopic Open surgery Mean Constant
score WMD, 6.20 (95% CI, 6.14 to 18.54)
(n17) (n15)onck et al18
IS32 (36 shoulders) Arthroscopic
(n17)Open surgery(n15)
Mean ROM: Active elevation(12mo)
WMD, 2.20 (95% CI, 13.43 to 17.83)
(n17) (n15) Abduction WMD, 15.00 (95% CI, 2.68 to 32.68)(n17)
(n15) External rotation (passive) WMD, 10.70 (95% CI, 30.72 to
9.32)(n17) (n33) Internal rotation (passive) WMD, 3.60 (95% CI,
5.71 to 12.91)
usby et al17
IS39 Arthroscopic
(n11)Open surgery(n13)
Mean muscle strength:external rotation at 60/s
3mo: WMD, 7.00 (95% CI, 49.45 to35.45)
(n14) (n17) 6mo: WMD, 3.00 (95% CI, 45.00 to39.00)
(n13) (n17) 12mo: WMD, 15.00 (95% CI, 60.72 to30.72)
(n13) (n18) 96mo: WMD, 21.00 (95% CI, 19.06 to61.06)
(n11) (n13) Mean muscle strength:external rotation at 180/s
3mo: WMD, 3.00 (95% CI, 40.21 to34.21)
(n14) (n17) 6mo: WMD, 7.00 (95% CI, 25.40 to 39.40)(n13) (n17)
12mo: WMD, 0.0 (95% CI, 37.47 to 37.47)(n13) (n18) 96mo: WMD, 14.00
(95% CI, 24.94 to
24.94)(n11) (n13) Mean muscle strength: internal
rotation at 60/s3mo: WMD, 16.00 (95% CI, 65.63 to
97.36)(n14) (n17) 6mo: WMD, 15.00 (95% CI, 52.74 to
82.74)(n13) (n17) 12mo: WMD, 10.00 (95% CI, 58.03 to
78.03)(n13) (n18) 96mo: WMD, 57.00 (95% CI, 14.28 to
128.28)(n11) (n13) Mean muscle strength: internal
rotation at 180/s3mo: WMD, 1.00 (95% CI, 66.84 to
68.84)
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2011APPENDIX 2: DATA EXTRACTIONSYSTEMATIC REVIEWS (Contd)Author
Total No. of Patients Treatment Placebo Control/Comparison Outcome
Measures Effect Size
(n14) (n17) 6mo: WMD, 21.00 (95% CI, 36.43 to78.43)
(n13) (n17) 12mo: WMD, 17.00 (95% CI, 42.17 to76.17)
(n13) (n18) 96mo: WMD, 45.00 (95% CI, 17.59 to107.59)
chs et al19 44 Arthroscopic surgery Open surgery Strength No
difference (no data given)S (n19) (n 22) Improvement
(participant
evaluation, Moderate, orcomplete improvement)
12mo: RR0.94 (95% CI, 0.78 to 1.12)
Open surgical decompression: Neer vs modified Neer
techniquegvarrson et al22 20 Neer technique Modified Neer technique
Mean degrees of movement
(8wk)From baseline to 8-wk follow-up:Flexion: Neer: 115 to 150
vs modified
Neer: 125 to 160Extension: Neer: 40 to 50 vs modified
Neer: 40 to 55 Abduction: Neer: 105 to145 vs modified Neer: 80
to 160
Exo-rotation: Neer: 45 to 60 vs modifiedNeer: 50 to 65
Endo-rotation: Neer: 65 to 70 vs modifiedNeer: 70 to 70
Arthroscopic vs open removal of calcium depositbenthaler et al23
38 Arthroscopic surgery
(n14)Open surgery(n19)
Mean pain score (VAS)(16mo)
WMD, 0.30 (95% CI, 1.46 to 0.86)
lcific tendinitis Mean shoulder function (VAS)(16mo)
WMD, 0.50 (95% CI, 2.08 to 1.08)
Improvement: mean time ofphysiotherapy (wk)
WMD, 5.00 (95% CI, 10.51 to 20.51)
Holium-laser vs electrocautery in arthroscopic subacromial
decompressionurphy et al24)S
48 (49 shoulders) Arthroscopicacromioplastyusing a
Holiumlaser
Arthroscopic acromioplastyusing electrocautery
Mean UCLA score 3mo: WMD, 1.00 (95% CI, 2.99 to 0.99)
(n25) (n24) 6mo: WMD, 1.00 (95% CI, 3.32 to 1.32)12mo: WMD, 2.00
(95% CI 0.53 to 4.53)
(n25) (n24) Mean ASES score 3mo: WMD, 7.00 (95% CI, 8.85 to
14.85)6mo: WMD, 8.00 (95% CI, 15.62 to0.38) ifo electrocautery.
12mo: WMD, 3.00 (95% CI, 5.96 to 11.96)
breviations: 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 innotonous work
(range, 036); WMD, weighted mean difference; VAS, visual analog
scale.
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Everts etSIS
Abbreviatisignificant
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or Treatment Placebo Control/Comparison Outcome Measures and FU
TimeResultsStatistical
(P) ResultsWords
SURGERYSubacromial decompression vs radiofrequency-based plasma
microtenotomy
Treatment vs comparisonet al25 ASD RF-based arthroscopic
microtenotomyVAS (range, 010) (baseline) .470 Mean SD, 81 vs
81
natussis
(n30) (n30) ASES (range max100) (baseline) .314 393 vs 394
UCLA (range max35) (baseline) .510 162 vs 172Constant score
(range max100)
(baseline).137 514 vs 5111
VAS (range, 010) (3mo, 6mo, 1y) .416 The pain reduction profile
was statisticallysimilar for both groups.
ASES (range max100) (3mo,6mo, 1y)
.964 Improvement across time was statisticallysimilar for both
groups.
UCLA (range max35) (3mo,6mo, 1y)
.794 Improvement across time was statisticallysimilar for both
groups.
Constant score (range max100)(3mo, 6mo, 1y)
.978 Improvement in scores across time werestatistically similar
for both groups.
PLG as add-on to OSDal26 PLG injection after OSD
(n20)OSD only(n20)
Pain (VAS) (6wk) .001 PLG vs control, decrease in pain ifo
PLG(no exact data given)
Use of pain medication (3mo) no P given PLG used less pain
medication thancontrol (no exact data given)
Shoulder index score (calculatedfrom ADL score and VAS
score)(6wk)
.001 Sig. better results ifo patients with PLG(no exact data
given)
Instability score (self-assessment) (VAS)
NS Preoperative: PLG: mean SD, 3.32.7 vscontrol: 3.72.9
(6wk) .13 6wk: PLG: 1.10.3 vs control: 2.02.0ADL (questionnaire)
(6wk) .05 more activities ifo PLG (no exact data
given)ROM .001 2wk: Sig. improvement ifo PLG(12wk) p0.05 6 and
12wk: Sig. improvement ifo PLG
ons: ADL, activities of daily living; ASD, arthroscopic
subacromial decompression; FU, follow-up; ifo, in favor of; RF,
radiofrequency; max, maximum; NS, not significant; Sig.,; VAS,
visual analog scale (range, 010).
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Author Treatment Placebo Control/ComparisonOutcome Measures and
FU
TimeResultsStatistical
(P) ResultsWordsPOSTSURGERYHultenheim PG (active-assisted TG
Pain during activity PG vs TG, median (range)Klintberg et al27 ROM
exercises on day 1 of
surgery (3/d) andstrengthening exercises after6wk
(active- assisted dynamicexercises for rotatorcuff after 6wk
(3/d)and strengtheningexercises after 8wkpost operative
(VAS) NS Baseline: 72 (30100) vs 67
SIS (3/d)(n13) (24mo) No P given (097)(n20) No P given 3mo: 5
(078) vs 20 (075)
No P given 6mo: 14 (070) vs 12 (070)No P given 12mo: 2 (035) vs
23 (084)
PG vs TG, median (range)Pain during rest NS Baseline: 30 (972)
vs 50 (095)(VAS) No P given 3mo: 0 (063) vs 10 (082)(24mo) No P
given 6mo: 1 (063) vs 0 (030)
No P given 12mo: 0 (033) vs 5 (046)PG vs TG, median (range)
ROM: (degrees) NS Baseline: 150 (95170) vs 145 (90180)
Flexion: .05 6wk: 160 (120180) vs 140 (85170)No P given 3mo: 160
(140165) vs 150 (90170)No P given 6mo: 165 (110180) vs 150
(85180)No P given 12mo: 160 (140180) vs 150 (130180)
Extension PG vs TG, median (range)NS Baseline: 40 (2555) vs 40
(1575)No P given.05 3mo: 50 (4060) vs 40 (2070) ifo PGNo P given
6mo: 50 (3070) vs 40 (2070)No P given 12mo: 50 (3560) vs 40
(3065)
Abduction NS PG vs TG, median (range)No P given Baseline: 170
(50180) vs 150 (25
180).05 3mo: 180 (170180) vs 160 (70180)
ifo PGNo P given 6mo: 180 (90180) vs 170 (85180).05 12mo: 180
(130180) vs 170 (80180)
ifo PGShoulder function:
Constant score(24mo)
NS PG vs TG, median (range)
(no P given) Baseline: 57 (4089) vs 46 (1778).05 6wk: 67 (3496)
vs 48 (1878), ifo PGNo P given 3mo: 80 (6088) vs 59 (1994)No P
given 6mo: 84 (3594) vs 72 (3097)No P given 12mo: 87 (6396) vs 69
(2297)
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20111912APPENDIX 4: DATA EXTRACTIONADDITIONAL RCTS (Contd)
Author Treatment Placebo Control/ComparisonOutcome Measures and
FU
TimeResultsStatistical
(P) ResultsWords
ansen et al28 ASD plus ketoprofen 200mg1/d for 6wk
(n21)
ASDplusplacebo
(n20)
No. of patients showingmild or no pain
.05 Treatment vs placebo:6wk: 16/19 vs 9/19
NS 2y: 14/17 vs 10/15(No P given)
Mean UCLA score .05 Treatment: mean (range), 16 (827) atbaseline
to 30 (1635) at 6-wk FUvs placebo:
16 (1922) at baseline to 26 (1635) at6-wk FU
NS At 2-y FU: Treatment: 31 (1735) vsplacebo 29 (1635)
(No P given)Active forward flexion
(degrees).05 Treatment: 145 (80180) at baseline
to 173 (90180) at 6-wkFU vs placebo: 149 (70180) to 169
(90180) at 6-wk FU.NS At 2-y FU: data not given(No P given)
Active abduction(degrees)
.05 Treatment: 124 (50180) at baselineto 169 (90180) at 6-wk
FU vs placebo: 128 (45180) atbaseline to 165 (70180) at 6-wk
FU
NS At 2-y FU: data not given(No P given) Study group vs control
group
(Mean SD)a et al29 Study group: pain pump with
0.375% ropivacaine infusionat continuous rate of 5mL/hin the
subacromial spaceplus rehabilitation (ie, asling for the first
night, freeROM on first day aftersurgery and
physiotherapy)(n25)
Control group onlyrehabilitation (n25)
UCLA score(2y)Constant score(2y)
.137
.845
.831
.243
Baseline: 203 vs 1842y: 333 vs 334Study group vs. control
group
(Mean SD)Baseline: 6010 vs 6011 2 years:
948 vs 965
iations: FU, follow-up; ifo, in favor of; NS, not significant;
PG, progressive group; TG, traditional group; VAS, visual analog
scale (range, 010).
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Rehabil Vol 92, November 2011
Effectiveness of Surgical and Postsurgical Interventions for the
Subacromial Impingement Syndrom ...MethodSearch StrategyInclusion
CriteriaStudy SelectionCategorization of the Relevant
LiteratureData ExtractionMethodologic Quality AssessmentData
Synthesis
ResultsStudy CharacteristicsMethodologic QualityEffectiveness of
Surgical and Postsurgical Interventions to Treat SIS1.
Effectiveness of Surgery1.1. Arthroscopic or Open Subacromial
Decompression Versus Conservative TreatmentSystematic review
1.2. Arthroscopic Versus Open Subacromial
DecompressionSystematic review
1.3. OSD: Neer Versus Modified Neer Technique1.4. ASD Versus OSD
to Remove Calcium Deposit in Calcific TendonitisSystematic
review
1.5. Electrocautery Versus Holium Laser in ASDSystematic
review
1.6. ASD Versus Radiofrequency-Based Plasma MicrotenotomyRecent
RCT
1.7. Platelet-Leukocyte Gel as Add-On Therapy in OSDAdditional
RCT
2. Effectiveness of Postsurgery Treatments2.1. Early Activation
Versus Protective Physiotherapy After ASDAdditional RCT
2.2. Ketoprofen Versus Placebo After ASDAdditional RCT
2.3. Pain Pump After ASDAdditional RCT
DiscussionStudy Limitations
ConclusionsAppendix 1: Search
strategyPubMedEmbaseCINAHLPEDro
AcknowledgementReferences