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Review
Subacromial impingement syndrome—effectiveness of physiotherapy and manual therapy Lukas Gebremariam,1 Elaine M Hay,2 Renske van der Sande,1 Willem D Rinkel,3 Bart W Koes,1 Bionka M A Huisstede1,3 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ bjsports-2012-091802) 1
Department of General Practice, Erasmus MC— University Medical Center Rotterdam, Rotterdam, The Netherlands 2 Arthritis Research Campaign National Primary Care Centre, Keele University, Keele, UK 3 Department of Rehabilitation Medicine, Erasmus MC— University Medical Center Rotterdam, Rotterdam, The Netherlands Correspondence to Dr Bionka M A Huisstede, Department of Rehabilitation, Erasmus MC—University Medical Center Rotterdam, Room H-016, PO Box 2040, Rotterdam 3000 CA, The Netherlands; [email protected] Accepted 13 October 2013 Published Online First 11 November 2013
ABSTRACT Background The subacromial impingement syndrome (SIS) includes the rotator cuff syndrome, tendonitis and bursitis of the shoulder. Treatment includes surgical and non-surgical modalities. Non-surgical treatment is used to reduce pain, to decrease the subacromial inflammation, to heal the compromised rotator cuff and to restore satisfactory function of the shoulder. To select the most appropriate non-surgical intervention and to identify gaps in scientific knowledge, we explored the effectiveness of the interventions used, concentrating on the effectiveness of physiotherapy and manual therapy. Methods The Cochrane Library, PubMed, EMBASE, PEDro and CINAHL were searched for relevant systematic reviews and randomised clinical trials (RCTs). Two reviewers independently extracted data and assessed the methodological quality. A best-evidence synthesis was used to summarise the results. Results Two reviews and 10 RCTs were included. One RCT studied manual therapy as an add-on therapy to self-training. All other studies studied the effect of physiotherapy: effectiveness of exercise therapy, mobilisation as an add-on therapy to exercises, ultrasound, laser and pulsed electromagnetic field. Moderate evidence was found for the effectiveness of hyperthermia compared to exercise therapy or ultrasound in the short term. Hyperthermia and exercise therapy were more effective in comparison to controls or placebo in the short term (moderate evidence). For the effectiveness of hyperthermia, no midterm or long-term results were studied. In the midterm, exercise therapy gave the best results (moderate evidence) compared to placebo or controls. For other interventions, conflicting, limited or no evidence was found. Conclusions Some physiotherapeutic treatments seem to be promising (moderate evidence) to treat SIS, but more research is needed before firm conclusions can be drawn.
INTRODUCTION
To cite: Gebremariam L, Hay EM, van der Sande R, et al. Br J Sports Med 2014;48:1202–1208.
The subacromial impingement syndrome was included as one of the 23 disorders classified as specific disorders in the complaints of the arm, neck and/or shoulder (CANS) model. The CANS model was developed by 47 experts in the field of upperextremity disorders. These experts were delegates from 11 medical and paramedical professional associations. Multidisciplinary agreement was achieved on the term, definition and classification of CANS. The model was developed to help professionals classify patients unambiguously in order to improve multidisciplinary cooperation and make data of scientific studies better comparable. CANS entities are common. The disorders are painful, disabling and a
Gebremariam L, et al. Br J Sports Med 2014;48:1202–1208. doi:10.1136/bjsports-2012-091802
burden on healthcare resources.1 Women are more affected than men.2 3 In 19% of the patients, the discomforts were chronic.2 Of those with chronic CANS, 56% reported discomforts of the shoulder. In general practice, 85% of patients with shoulder pain were diagnosed with rotator cuff tendinopathy; 74% showed signs of impingement.4 One of the specific disorders mentioned in the CANS model is, as aforementioned, the subacromial impingement syndrome. Within this model, the term ‘subacromial impingement syndrome’ includes the rotator cuff syndrome —tendonitis of the m. infraspinatus, m. supraspinatus and m. subscapularis—and bursitis of the shoulder area. For this study, we followed this consensus. Patients with SIS suffer from pain, weakness and loss of movement of the affected shoulder.5 The occurrence of SIS is associated with highly repetitive work, forceful exertion in work, awkward postures and high psychosocial job demand.6 Surgical and non-surgical strategies are used to treat SIS. An article on the effectiveness of postsurgical interventions for SIS has already been published.7 The goal of non-surgical treatment is to decrease the subacromial inflammation, reduce the pain, allow healing of the compromised rotator cuff and restore satisfactory function of the shoulder.8 To help physicians select the most appropriate non-surgical intervention and to identify gaps in scientific knowledge, we explored the effectiveness of these interventions. Articles on the evidence for effectiveness of extracorporeal shock wave therapy and medication (oral, injected and patched) have been published elsewhere.9 10 This article concentrates on the effectiveness of physiotherapy and manual therapy as treatment for SIS.
METHODS Search strategy The Cochrane Library, PubMed, EMBASE, PEDro and CINAHL were searched up to March 2009. Keywords related to SIS and interventions were included. Online supplementary appendix 1 shows the complete search strategy.
Inclusion criteria Systematic reviews and randomised clinical trials (RCTs) were included if they fulfilled all of the following criteria: (A) SIS, not caused by an acute trauma or any systemic disease as described in the definition of CANS, was studied (B) an intervention for treating SIS was evaluated, (C) results on pain, function or recovery were reported and (D) a follow-up period of ≥2 weeks was reported. There were no language restrictions. 1 of 8
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Review After the full-text articles were included, we divided the included studies into different treatment groups for which separate reviews could be conducted. One of these groups concerned physiotherapeutic interventions. In this review, only studies were included in which physiotherapeutic interventions were compared to placebo, no treatment or another non-surgical treatment.
Study selection Two reviewers (BMAH and LG) independently applied the inclusion criteria to select potentially relevant studies from the title, abstracts and full-text articles, respectively. A consensus method was used to solve any disagreements concerning inclusion of studies, and a third reviewer (BWK) was consulted if disagreement persisted.
Categorisation of the relevant literature Relevant articles are categorised under three 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; and Additional RCTs describes all RCTs concerning an intervention that has not yet been described in a systematic review.
Data extraction Two pairs of authors (RvdS/LG and BMAH/WDR) independently extracted data from the included articles. Information was collected on the study population, interventions and outcome measures. A consensus procedure was used to solve any disagreement between the authors. Results were reported in the short term (≤3 months), midterm (4–6 months) and long term (>6 months).
used the authors’ definitions of high and low quality for the included studies.
Data synthesis A quantitative analysis of the studies was not possible due to the heterogeneity of the outcome measures. Therefore, we summarised the results using best-evidence synthesis.12–14 The article was included in the best-evidence synthesis only if a comparison was made between the groups and the level of significance was reported. The results of the study were labelled ‘significant’ if one of the three outcome measures on pain, function or recovery reported significant results. The levels of evidence for effectiveness are given in box 1.
RESULTS Characteristics of the included studies The initial search resulted in five reviews from the Cochrane library. Through PubMed 5 reviews and 215 RCTs, through EMBASE 21 reviews and 193 RCTs, through CINAHL 141 reviews/RCTs and through PEDro 0 reviews and 13 RCTs were identified. Finally, 2 reviews and 10 RCTs were included. The first systematic review of Green et al15 included nine RCTs (n=525) on acupuncture for shoulder pain versus placebo or other interventions. One of these RCTs compared ultrasound to acupuncture. The second systematic review of Green et al16 included 26 RCTs exploring physiotherapy versus placebo or other interventions for various shoulder discomforts; 10 RCTs (n=575) reported on physiotherapy to treat SIS. The characteristics of the included studies are listed in online supplementary appendix 2A–C. A flow chart of the literature search is found in online supplementary appendix 3.
Methodological quality assessment
Methodological quality assessment Two reviewers (LG, M S Randsdorp) independently assessed the methodological quality of each RCT using Furlan’s 12 criteria (table 1).11 Each item was scored as ‘yes’, ‘no’ or ‘unclear’. ‘High quality’ was defined as a ‘yes’ score of ≥50%. A consensus procedure was used to solve disagreement between the reviewers. In a (Cochrane) review, the use of a methodological quality assessment is a standard procedure. We describe the methodological quality scale/criteria that were used in the review and
The results of the methodological quality assessment are presented in table 2. Five (of the 10 included) RCTs were of high quality. The most prevalent methodological flaws were: (1) care provider not blinded and (2) unclear whether allocation was concealed. The RCT included from the review of Green et al15 on acupuncture was of high quality. In this review, a methodological quality list was used consisting of 10 items as presented in the Cochrane handbook. The other systematic review of Green et al16 on physiotherapeutic interventions used a methodological scoring list of 11 items. All 11 RCTs in this review
Table 1 Methodological quality assessment: assessing the risk of bias A B C
D
E F
2 of 8
1. Was the method of randomisation adequate? 2. Was the treatment allocation concealed? Was knowledge of the allocated interventions adequately prevented during the study? 3. Was the patient blinded to the intervention? 4. Was the care provider blinded to the intervention? 5. Was the outcome assessor blinded to the intervention? Were incomplete outcome data adequately addressed? 6. Was the dropout rate described and acceptable? 7. Were all randomised participants analysed in the group to which they were allocated? 8. Are reports of the study free of suggestion of selective outcome reporting? Other sources of potential bias: 9.Were the groups similar at baseline regarding the most important prognostic indicators? 10. Were cointerventions avoided or similar? 11. Was the compliance acceptable in all groups? 12. Was the timing of the outcome assessment similar in all groups?
Box 1 Levels of evidence Strong evidence: consistent (ie, when ≥75% of the trials report the same findings) positive (significant) findings within multiple higher quality randomised clinical trials (RCTs). Moderate evidence: consistent positive (significant) findings within multiple lower quality RCTs and/or one high-quality RCT. Limited evidence for effectiveness: positive (significant) findings within one low-quality RCT. Conflicting evidence: provided by conflicting (significant) findings in the RCTs (
Review
Subacromial impingement syndrome—effectiveness of physiotherapy and manual therapy Lukas Gebremariam,1 Elaine M Hay,2 Renske van der Sande,1 Willem D Rinkel,3 Bart W Koes,1 Bionka M A Huisstede1,3 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ bjsports-2012-091802) 1
Department of General Practice, Erasmus MC— University Medical Center Rotterdam, Rotterdam, The Netherlands 2 Arthritis Research Campaign National Primary Care Centre, Keele University, Keele, UK 3 Department of Rehabilitation Medicine, Erasmus MC— University Medical Center Rotterdam, Rotterdam, The Netherlands Correspondence to Dr Bionka M A Huisstede, Department of Rehabilitation, Erasmus MC—University Medical Center Rotterdam, Room H-016, PO Box 2040, Rotterdam 3000 CA, The Netherlands; [email protected] Accepted 13 October 2013 Published Online First 11 November 2013
ABSTRACT Background The subacromial impingement syndrome (SIS) includes the rotator cuff syndrome, tendonitis and bursitis of the shoulder. Treatment includes surgical and non-surgical modalities. Non-surgical treatment is used to reduce pain, to decrease the subacromial inflammation, to heal the compromised rotator cuff and to restore satisfactory function of the shoulder. To select the most appropriate non-surgical intervention and to identify gaps in scientific knowledge, we explored the effectiveness of the interventions used, concentrating on the effectiveness of physiotherapy and manual therapy. Methods The Cochrane Library, PubMed, EMBASE, PEDro and CINAHL were searched for relevant systematic reviews and randomised clinical trials (RCTs). Two reviewers independently extracted data and assessed the methodological quality. A best-evidence synthesis was used to summarise the results. Results Two reviews and 10 RCTs were included. One RCT studied manual therapy as an add-on therapy to self-training. All other studies studied the effect of physiotherapy: effectiveness of exercise therapy, mobilisation as an add-on therapy to exercises, ultrasound, laser and pulsed electromagnetic field. Moderate evidence was found for the effectiveness of hyperthermia compared to exercise therapy or ultrasound in the short term. Hyperthermia and exercise therapy were more effective in comparison to controls or placebo in the short term (moderate evidence). For the effectiveness of hyperthermia, no midterm or long-term results were studied. In the midterm, exercise therapy gave the best results (moderate evidence) compared to placebo or controls. For other interventions, conflicting, limited or no evidence was found. Conclusions Some physiotherapeutic treatments seem to be promising (moderate evidence) to treat SIS, but more research is needed before firm conclusions can be drawn.
INTRODUCTION
To cite: Gebremariam L, Hay EM, van der Sande R, et al. Br J Sports Med 2014;48:1202–1208.
The subacromial impingement syndrome was included as one of the 23 disorders classified as specific disorders in the complaints of the arm, neck and/or shoulder (CANS) model. The CANS model was developed by 47 experts in the field of upperextremity disorders. These experts were delegates from 11 medical and paramedical professional associations. Multidisciplinary agreement was achieved on the term, definition and classification of CANS. The model was developed to help professionals classify patients unambiguously in order to improve multidisciplinary cooperation and make data of scientific studies better comparable. CANS entities are common. The disorders are painful, disabling and a
Gebremariam L, et al. Br J Sports Med 2014;48:1202–1208. doi:10.1136/bjsports-2012-091802
burden on healthcare resources.1 Women are more affected than men.2 3 In 19% of the patients, the discomforts were chronic.2 Of those with chronic CANS, 56% reported discomforts of the shoulder. In general practice, 85% of patients with shoulder pain were diagnosed with rotator cuff tendinopathy; 74% showed signs of impingement.4 One of the specific disorders mentioned in the CANS model is, as aforementioned, the subacromial impingement syndrome. Within this model, the term ‘subacromial impingement syndrome’ includes the rotator cuff syndrome —tendonitis of the m. infraspinatus, m. supraspinatus and m. subscapularis—and bursitis of the shoulder area. For this study, we followed this consensus. Patients with SIS suffer from pain, weakness and loss of movement of the affected shoulder.5 The occurrence of SIS is associated with highly repetitive work, forceful exertion in work, awkward postures and high psychosocial job demand.6 Surgical and non-surgical strategies are used to treat SIS. An article on the effectiveness of postsurgical interventions for SIS has already been published.7 The goal of non-surgical treatment is to decrease the subacromial inflammation, reduce the pain, allow healing of the compromised rotator cuff and restore satisfactory function of the shoulder.8 To help physicians select the most appropriate non-surgical intervention and to identify gaps in scientific knowledge, we explored the effectiveness of these interventions. Articles on the evidence for effectiveness of extracorporeal shock wave therapy and medication (oral, injected and patched) have been published elsewhere.9 10 This article concentrates on the effectiveness of physiotherapy and manual therapy as treatment for SIS.
METHODS Search strategy The Cochrane Library, PubMed, EMBASE, PEDro and CINAHL were searched up to March 2009. Keywords related to SIS and interventions were included. Online supplementary appendix 1 shows the complete search strategy.
Inclusion criteria Systematic reviews and randomised clinical trials (RCTs) were included if they fulfilled all of the following criteria: (A) SIS, not caused by an acute trauma or any systemic disease as described in the definition of CANS, was studied (B) an intervention for treating SIS was evaluated, (C) results on pain, function or recovery were reported and (D) a follow-up period of ≥2 weeks was reported. There were no language restrictions. 1 of 8
Downloaded from http://bjsm.bmj.com/ on March 9, 2018 - Published by group.bmj.com
Review After the full-text articles were included, we divided the included studies into different treatment groups for which separate reviews could be conducted. One of these groups concerned physiotherapeutic interventions. In this review, only studies were included in which physiotherapeutic interventions were compared to placebo, no treatment or another non-surgical treatment.
Study selection Two reviewers (BMAH and LG) independently applied the inclusion criteria to select potentially relevant studies from the title, abstracts and full-text articles, respectively. A consensus method was used to solve any disagreements concerning inclusion of studies, and a third reviewer (BWK) was consulted if disagreement persisted.
Categorisation of the relevant literature Relevant articles are categorised under three 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; and Additional RCTs describes all RCTs concerning an intervention that has not yet been described in a systematic review.
Data extraction Two pairs of authors (RvdS/LG and BMAH/WDR) independently extracted data from the included articles. Information was collected on the study population, interventions and outcome measures. A consensus procedure was used to solve any disagreement between the authors. Results were reported in the short term (≤3 months), midterm (4–6 months) and long term (>6 months).
used the authors’ definitions of high and low quality for the included studies.
Data synthesis A quantitative analysis of the studies was not possible due to the heterogeneity of the outcome measures. Therefore, we summarised the results using best-evidence synthesis.12–14 The article was included in the best-evidence synthesis only if a comparison was made between the groups and the level of significance was reported. The results of the study were labelled ‘significant’ if one of the three outcome measures on pain, function or recovery reported significant results. The levels of evidence for effectiveness are given in box 1.
RESULTS Characteristics of the included studies The initial search resulted in five reviews from the Cochrane library. Through PubMed 5 reviews and 215 RCTs, through EMBASE 21 reviews and 193 RCTs, through CINAHL 141 reviews/RCTs and through PEDro 0 reviews and 13 RCTs were identified. Finally, 2 reviews and 10 RCTs were included. The first systematic review of Green et al15 included nine RCTs (n=525) on acupuncture for shoulder pain versus placebo or other interventions. One of these RCTs compared ultrasound to acupuncture. The second systematic review of Green et al16 included 26 RCTs exploring physiotherapy versus placebo or other interventions for various shoulder discomforts; 10 RCTs (n=575) reported on physiotherapy to treat SIS. The characteristics of the included studies are listed in online supplementary appendix 2A–C. A flow chart of the literature search is found in online supplementary appendix 3.
Methodological quality assessment
Methodological quality assessment Two reviewers (LG, M S Randsdorp) independently assessed the methodological quality of each RCT using Furlan’s 12 criteria (table 1).11 Each item was scored as ‘yes’, ‘no’ or ‘unclear’. ‘High quality’ was defined as a ‘yes’ score of ≥50%. A consensus procedure was used to solve disagreement between the reviewers. In a (Cochrane) review, the use of a methodological quality assessment is a standard procedure. We describe the methodological quality scale/criteria that were used in the review and
The results of the methodological quality assessment are presented in table 2. Five (of the 10 included) RCTs were of high quality. The most prevalent methodological flaws were: (1) care provider not blinded and (2) unclear whether allocation was concealed. The RCT included from the review of Green et al15 on acupuncture was of high quality. In this review, a methodological quality list was used consisting of 10 items as presented in the Cochrane handbook. The other systematic review of Green et al16 on physiotherapeutic interventions used a methodological scoring list of 11 items. All 11 RCTs in this review
Table 1 Methodological quality assessment: assessing the risk of bias A B C
D
E F
2 of 8
1. Was the method of randomisation adequate? 2. Was the treatment allocation concealed? Was knowledge of the allocated interventions adequately prevented during the study? 3. Was the patient blinded to the intervention? 4. Was the care provider blinded to the intervention? 5. Was the outcome assessor blinded to the intervention? Were incomplete outcome data adequately addressed? 6. Was the dropout rate described and acceptable? 7. Were all randomised participants analysed in the group to which they were allocated? 8. Are reports of the study free of suggestion of selective outcome reporting? Other sources of potential bias: 9.Were the groups similar at baseline regarding the most important prognostic indicators? 10. Were cointerventions avoided or similar? 11. Was the compliance acceptable in all groups? 12. Was the timing of the outcome assessment similar in all groups?
Box 1 Levels of evidence Strong evidence: consistent (ie, when ≥75% of the trials report the same findings) positive (significant) findings within multiple higher quality randomised clinical trials (RCTs). Moderate evidence: consistent positive (significant) findings within multiple lower quality RCTs and/or one high-quality RCT. Limited evidence for effectiveness: positive (significant) findings within one low-quality RCT. Conflicting evidence: provided by conflicting (significant) findings in the RCTs (
