Treatments for Shoulder Impingement Syndrome

Many treatments for shoulder impingement syndrome (SIS) are available in clinical practice; some of which have already been compared with other treatments by various investigators. However, a comprehensive treatment comparison is lacking. Several widely used electronic databases were searched for eligible studies. The outcome measurements were the pain score and the Constant–Murley score (CMS). Direct comparisons were performed using the conventional pair-wise meta-analysis method, while a network meta-analysis based on the Bayesian model was used to calculate the results of all potentially possible comparisons and rank probabilities. Included in the meta-analysis procedure were 33 randomized controlled trials involving 2300 patients. Good agreement was demonstrated between the results of the pair-wise meta-analyses and the network meta-analyses. Regarding nonoperative treatments, with respect to the pain score, combined treatments composed of exercise and other therapies tended to yield better effects than single-intervention therapies. Localized drug injections that were combined with exercise showed better treatment effects than any other treatments, whereas worse effects were observed when such injections were used alone. Regarding the CMS, most combined treatments based on exercise also demonstrated better effects than exercise alone. Regarding surgical treatments, according to the pain score and the CMS, arthroscopic subacromial decompression (ASD) together with treatments derived from it, such as ASD combined with radiofrequency and arthroscopic bursectomy, showed better effects than open subacromial decompression (OSD) and OSD combined with the injection of platelet-leukocyte gel. Exercise therapy also demonstrated good peri-Chao Jiang, MSc le, MD, Kabir, MD Exercise and other exercise-based therapies, such as kinesio taping, specific exercises, and acupuncture, are ideal treatments for patients at an early stage of SIS. However, low-level laser therapy and the localized injection of nonsteroidal anti-inflammatory drugs are not recommended. For patients who have a long-term disease course, operative treatments may be considered, with standard ASD surgery preferred over arthroscopic bursectomy and the open surgical technique for subacromial decompression. Notwithstanding, the choice of surgery should be made cautiously because similar outcomes may also be achieved by the implementation of exercise therapy. (Medicine 94(10):e510) Abbreviations: ACU = acupuncture therapy, ASD = routine arthroscopic subacromial decompression, CI = confidence interval, CMS = Constant–Murley score, COR = corticosteroid injection, DF = diacutaneous fibrolysis therapy, DIC = deviance information criterion, EXE = routine exercise treatment, HYA = hyaluronate injection, KT = kinesio taping therapy, LLLT = low-level laser therapy, MAN = manual therapy, MCMC = Markov chain Monte Carlo, MD = mean difference, MWD = microwave diathermy therapy, NON = no treatment/placebo, NRS = numerical rating scale, NSAID = nonsteroidal anti-inflammatory drug injection, onlyBUR = arthroscopic bursectomy without acromioplasty, OSD = open subacromial decompression, PEMF = pulsed electromagnetic field therapy, PLG = platelet-leukocyte gel injection, PSRF = potential scale reduction factor, RCT = randomized controlled trial, rESWT = radial extracorporeal shockwave therapy, RF = radiofrequency therapy, SE = specific exercise therapy, SIS = shoulder impingement syndrome, SUCRA = surface under the cumulative ranking curve, US = ultrasound therapy, VAS = visual analog scale. INTRODUCTION S houlder pain is a common presenting complaint from patients of all ages in daily clinical practice, affecting approximately one-third of individuals during their lifetime. Such pain may lead to the impairment of shoulder joint function and to severe reduction in quality of life. Shoulder impingement syndrome, which is defined as the compression of the rotator cuff and the subacromial bursa, is considered to be one of the most common causes of shoulder pain and may be cited as a contributing factor to shoulder pain in up to 65% of cases. The typical sign of SIS is pain localized to the anterolateral acromial area, which may also radiate to the lateral midhumerus. Pain at night is another important complaint in these patients. Concurrently, a general loss of muscle strength may be noted. Neer graded SIS into 3 different stages. In stage I, the typical characteristics are reversible lesions with edema and ients younger than 25 years are in this ronic inflammation or repeated episodes o histomorphological changes, such as www.md-journal.com | 1 (8) (9) (10) fibrosis and thickening of the supraspinatus, the long biceps tendon, and subacromial bursae. Patients in this stage are usually between 25 and 40 years of age. In stage III, in patients more than 40 years of age, tears of the rotator cuff, rupture of the biceps tendon, and bony changes may be observed, accompanied by significant tendon degeneration following a long history of refractory tendinitis. The main goals of SIS treatments are to relieve pain and to solve the mechanical problem causing the functional impairment. The SIS treatment strategy varies according to disease stage. At an early stage of SIS, which usually refers to stage I or early stage II, some nonoperative treatments may be effective, such as muscle exercises, for example, the training of the periscapular muscles (pectoralis minor, trapezius, serratus, and rhomboids) and strengthening of the rotator cuff (supraspinatus, infraspinatus, teres minor, and subscapularis), which functions as the stabilizer of the shoulder joint. Some investigators have also reported on many other nonoperative treatment methods, such as pulsed electromagnetic field therapy, manual therapy, kinesio taping therapy, localized drug injection of corticosteroids, hyaluronate, or NSAIDs, diacutaneous fibrolysis therapy, specific exercise therapy that includes concentric and eccentric exercises for the scapula stabilizers and dynamic humeral centering and scapular stabilization exercises, microwave diathermy therapy, ultrasound therapy, low-level laser therapy, radial extracorporeal shockwave therapy, and acupuncture therapy. After these treatments have been performed, some patients may be relieved of SIS. However, for other patients, operative treatment should be considered. The most prevalent surgical methods are ASD and OSD. Additionally, some adjustments have been made based on these 2 classic techniques, for example, arthroscopic bursectomy, ASD combined with radiofrequency therapy, and OSD combined with localized platelet-leukocyte gel injection (PLG). However, the abundance of treatment choices do not necessarily facilitate the physician’s decision making but rather indicates that no consensus exists regarding which treatment options are suitable. Many RCTs have been conducted to compare the effectiveness of different treatments, supporting certain conclusions. Some systematic reviews have also been published that concentrated only on the pair-wise comparison of different treatments, but no review including all of the available treatments has been conducted. Due to the limitations of the existing reviews and the fact that many relatively new studies have been published, a prominent need exists to conduct an accurate and comprehensive review of this topic. Network meta-analysis enables comparisons of the effectiveness of all treatments considered. Furthermore, the statistical method based on Bayesian theory enables calculation of the rank probability for each treatment. In this type of analysis, investigators may consider all of the possible relevant treatments. Clearly, this approach is in accordance with actual situations in daily clinical practice. In this review, we have endeavored to provide useful information regarding comparisons among all treatments for SIS. We hope that the results will aid physician decision making. MATERIALS AND METHODS Dong et al Eligibility Criteria This study was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. 2 | www.md-journal.com Since this study was a review of published studies, ethical approval was not required. Randomized controlled trials that included all of the following criteria were considered eligible: adults older than 18 years; a diagnosis of SIS, not caused by any other systemic disease or acute trauma; the evaluation of at least 2 SIS interventions, including placebo or sham treatment; reported results of pain relief or functional recovery; and reported results after at least 2 weeks of follow-up. Search Strategy Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from the inception of each database to 15 April 2014. The Medline and Embase databases were searched together via www.embase.com (Elsevier, The Netherlands). The search was conducted using the keywords shoulder, subacrom , supraspinat , rotator cuff, and impingement, and it was limited to RCTs (List 1). Additionally, all of the available reviews related to SIS treatments were manually screened for any additional possibly Medicine Volume 94, Number 10, March 2015