REVIEW ARTICLE (META-ANALYSIS)

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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: b.huisstede@erasmusmc.nl.003-9993/11/9211-00260$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

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Table 1: Methodologic Quality Assessment: Sources of Risk Bias

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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

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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

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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

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Table 5: CANS: Evidence for Effectiveness of Surgical and Postsurgical Interventions for Subacromial Impingement Syndrome

Surgery vs Conservative Postsurgery

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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

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stated that if an intention-to-treat analysis was conducted, theeffectiveness of surgery should be favorable.14

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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

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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

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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

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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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20111910APPENDIX 3: DATA EXTRACTIONRECENT RCTS

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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2011APPENDIX 4: DATA EXTRACTIONADDITIONAL RCTS

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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Hoe-HSIS

JarvelSIS

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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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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