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Suroto H, Anindita Satmoko B, Prajasari T, De Vega B, Wardhana TH, Samijo SK. Biodegradable vs nonbiodegradable suture anchors for rotator cuff repair: a systematic review and meta-analysis. EFORT Open Rev 2023; 8:731-747. [PMID: 37787481 PMCID: PMC10562948 DOI: 10.1530/eor-23-0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
Purpose The use of non-biodegradable suture anchors (NBSA) in arthroscopic rotator cuff repair (RCR) has increased significantly. However, several complications such as migration, chondral damage, revision, and imaging difficulties have been reported. Meanwhile, the effectiveness of biodegradable suture anchors (BSA) in overcoming such complications and achieving functional outcomes requires further study. Thus, we aim to compare the clinical outcomes and complications of RCR using BSA and NBSA using direct comparison studies. Methods Two independent reviewers conducted systematic searches in PubMed, Embase, Cochrane Library, and Web of Science from conception to September 2022. Using the RoB 2 and ROBINS-I tools, we assessed the included studies for bias. We applied GRADE to appraise our evidence. Our PROSPERO registration number is CRD42022354347. Results Six studies (two randomized controlled trials, one retrospective cohort, and three case-control studies) involving 423 patients were included (211 patients received BSA and 212 patients received NBSA). BSA was comparable to NBSA in forward flexion, abduction, external rotation, Constant-Murley score, and perianchor cyst formation (P = 0.97, 0.81, 0.56, 0.29, and 0.56, respectively). Retear rates were slightly higher while tendon healing was reduced in BSA compared to NBSA, but the differences were not significant (P = 0.35 and 0.35, respectively). Conclusion BSA and NBSA appear to yield similar shoulder functions and complications in rotator cuff repairs.
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Affiliation(s)
- Heri Suroto
- Department of Orthopedic and Traumatology, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | | | - Tabita Prajasari
- Department of Orthopedic and Traumatology, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Brigita De Vega
- Division of Surgery and Interventional Science, University College London, Royal Free Hospital Campus, United Kingdom
| | - Teddy Heri Wardhana
- Department of Orthopedic and Traumatology, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Steven K Samijo
- Department of Orthopedic and Traumatology, Zuyderland Medisch Centrum, Heerlen, Netherlands
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Cooper K, Alexander L, Brandie D, Brown VT, Greig L, Harrison I, MacLean C, Mitchell L, Morrissey D, Moss RA, Parkinson E, Pavlova AV, Shim J, Swinton PA. Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness. Health Technol Assess 2023; 27:1-389. [PMID: 37929629 PMCID: PMC10641714 DOI: 10.3310/tfws2748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Background Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy. Review questions (i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies? Methods A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021. Results Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship. Limitations Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made. Conclusion The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence. Future work There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes. Study registration This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review). Funding This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kay Cooper
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Lyndsay Alexander
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - David Brandie
- Sportscotland Institute of Sport, Airthrey Road, Stirling, UK
| | | | - Leon Greig
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Isabelle Harrison
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Colin MacLean
- Library Services, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Laura Mitchell
- NHS Grampian, Physiotherapy Department, Ellon Health Centre, Schoolhill, Ellon, Aberdeenshire, UK
| | - Dylan Morrissey
- William Harvey Research Institute, School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, Bancroft Road, London, UK
| | - Rachel Ann Moss
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Eva Parkinson
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | | | - Joanna Shim
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
| | - Paul Alan Swinton
- School of Health Sciences, Robert Gordon University, Garthdee Road, Aberdeen, UK
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Zhou T, Han C, Weng X. Present situation and development prospects of the diagnosis and treatment of rotator cuff tears. Front Surg 2023; 10:857821. [PMID: 37440927 PMCID: PMC10333593 DOI: 10.3389/fsurg.2023.857821] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/24/2023] [Indexed: 07/15/2023] Open
Abstract
Rotator cuff tears are an important cause of shoulder pain and are caused by degeneration or trauma of the shoulder tendon at the anatomical neck of the humeral head. The understanding and research of rotator cuff tears have a history of hundreds of years, and their etiology, diagnosis, and treatment have a complete system, but some detailed rules of diagnosis and treatment still have room for development. This research paper briefly introduces the diagnosis and treatment of rotator cuff tears. The current situation and its valuable research direction are described.
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Affiliation(s)
- Tianjun Zhou
- Department of Orthopedic, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
| | - Chang Han
- Department of Orthopedic, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
| | - Xisheng Weng
- Department of Orthopedic, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
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Signorino JA, Thompson AG, Hando BR, Young JL. Identifying Conservative Interventions for Individuals with Subacromial Pain Syndrome Prior to Undergoing a Subacromial Decompression: A Scoping Review. Int J Sports Phys Ther 2023; 18:293-308. [PMID: 37020452 PMCID: PMC10069387 DOI: 10.26603/001c.73312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 01/28/2023] [Indexed: 04/03/2023] Open
Abstract
Background Subacromial decompression (SAD) surgery remains a common treatment for individuals suffering from subacromial pain syndrome (SAPS), despite numerous studies indicating that SAD provides no benefit over conservative care. Surgical protocols typically recommend surgery only after exhausting conservative measures; however, there is no consensus in the published literature detailing what constitutes conservative care "best practice" before undergoing surgery. Purpose To describe conservative interventions received by individuals with SAPS prior to undergoing a SAD. Study Design Scoping review. Methods An electronic search using MEDLINE, CINAHL, PubMed, and Scopus databases was conducted. Peer-reviewed randomized controlled control trials and cohort studies published between January 2000 and February 2022 that included subjects diagnosed with SAPS who progressed to receive a SAD were eligible. Subjects who received previous or concurrent rotator cuff repair with SAPS were excluded. Conservative interventions and treatment details that subjects received prior to undergoing a SAD were extracted. Results Forty-seven studies were included after screening 1,426 studies. Thirty-six studies (76.6%) provided physical therapy (PT) services, and six studies (12.8%) included only a home exercise program. Twelve studies (25.5%) specifically detailed the delivered PT services, and 20 studies (42.6%) stated who provided the PT interventions. Subacromial injections (SI) (55.3%, n=26) and non-steroidal anti-inflammatories (NSAIDs) (31.9%, n=15) were the next most frequently delivered interventions. Thirteen studies (27.7%) included combined PT and SI. The duration of conservative care varied from 1.5 months to 16 months. Conclusion Conservative care that individuals with SAPS receive to prevent advancement to SAD appears inadequate based on the literature. Interventions, such as PT, SI, and NSAIDs, are either underreported or not offered to individuals with SAP prior to advancing to surgery. Many questions regarding optimal conservative management for SAPS persists. Level of Evidence n/a.
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Affiliation(s)
| | | | - Benjamin R Hando
- Division of Physical Therapy Shenandoah University
- DScPT Program Bellin College
- Special Warfare Training Wing
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Specific versus Non-Specific Exercises for Chronic Neck or Shoulder Pain: A Systematic Review. J Clin Med 2021; 10:jcm10245946. [PMID: 34945241 PMCID: PMC8706212 DOI: 10.3390/jcm10245946] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/07/2021] [Accepted: 12/11/2021] [Indexed: 02/02/2023] Open
Abstract
The current systematic review aimed to compare the effect of injury-focused (specific) exercises versus more general (non-specific) exercises on pain in patients with chronic neck or shoulder pain. We searched PubMed, EMBASE, and Web of Science. Two reviewers screened and selected studies, extracted outcomes, assessed risk of bias, and rated the quality of evidence. A total of nine eligible studies, represented in 13 articles, were identified, with a considerable risk of bias. One article investigated the acute effect of single bouts of exercise on pain and reported an immediate pain reduction after non-specific exercise. Regarding short-term effects, seven out of the nine studies found no differences in pain between interventions, with inconsistent results among two other studies. Concerning the long-term effects, while pain reduction seems to be favored by specific exercises (two out of four articles), the best format is still unclear. Based on the acute effects, a single bout of non-specific exercise seems to be a better option for pain-relief for patients with chronic neck or shoulder pain. For short-term effects, there are no differences in pain between specific and non-specific exercises. Regarding long-term effects, specific exercises seem to be the best option. Nevertheless, more studies are warranted.
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Return to work after subacromial decompression, diagnostic arthroscopy, or exercise therapy for shoulder impingement: a randomised, placebo-surgery controlled FIMPACT clinical trial with five-year follow-up. BMC Musculoskelet Disord 2021; 22:889. [PMID: 34666734 PMCID: PMC8527687 DOI: 10.1186/s12891-021-04768-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 09/24/2021] [Indexed: 11/15/2022] Open
Abstract
Background Arthroscopic subacromial decompression is one of the most commonly performed shoulder surgeries in the world. It is performed to treat patients with suspected shoulder impingement syndrome, i.e., subacromial pain syndrome. Only few studies have specifically assessed return-to-work rates after subacromial decompression surgery. All existing evidence comes from open, unblinded study designs and this lack of blinding introduces the potential for bias. We assessed return to work and its predictors in patients with shoulder impingement syndrome in a secondary analysis of a placebo-surgery controlled trial. Methods One hundred eighty-four patients in a randomised trial had undergone arthroscopic subacromial decompression (n = 57), diagnostic arthroscopy, a placebo surgical intervention, (n = 59), or exercise therapy (n = 68). We assessed return to work, defined as having returned to work for at least two follow-up visits by the primary 24-month time point, work status at 24 and 60 months, and trajectories of return to work per follow-up time point. Patients and outcome assessors were blinded to the assignment regarding the arthroscopic subacromial decompression vs. diagnostic arthroscopy comparison. We assessed the treatment effect on the full analysis set as the difference between the groups in return-to-work rates and work status at 24 months and at 60 months using Chi-square test and the predictors of return to work with logistic regression analysis. Results There was no difference in the trajectories of return to work between the study groups. By 24 months, 50 of 57 patients (88%) had returned to work in the arthroscopic subacromial decompression group, while the respective figures were 52 of 59 (88%) in the diagnostic arthroscopy group and 61 of 68 (90%) in the exercise therapy group. No clinically relevant predictors of return to work were found. The proportion of patients at work was 80% (147/184) at 24 months and 73% (124/184) at 60 months, with no difference between the treatment groups (p-values 0.842 and 0.943, respectively). Conclusions Arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy or exercise therapy on return to work in patients with shoulder impingement syndrome. We did not find clinically relevant predictors of return to work either. Trial registration ClinicalTrials.gov identifier NCT00428870.
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Responsiveness and minimal important change of the Oxford Shoulder Score, EQ-5D, and the Fear-Avoidance Belief Questionnaire Physical Activity subscale in patients undergoing arthroscopic subacromial decompression. JSES Int 2021; 5:869-874. [PMID: 34505098 PMCID: PMC8411058 DOI: 10.1016/j.jseint.2021.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction Adequate responsiveness and knowledge of the minimal important change (MIC) is essential when using patient-reported outcome measures to assess treatment efficacy. Objective The objective of this study was to evaluate the responsiveness and MIC of common outcomes in patients with subacromial impingement syndrome undergoing arthroscopic subacromial decompression. Methods At baseline and 6 months after surgery, patients completed the Oxford Shoulder Score (OSS), EQ-5D 5-level utility index, EQ visual analogue scale, Fear-Avoidance Belief Questionnaire Physical Activity subscale (FABQ-PA), assessed pain (pain visual analogue scale), and Subjective Shoulder Value. Furthermore, at the 6-month follow-up, patients assessed the overall change with a Global Rating of Change Scale. Responsiveness was examined by analyzing the area under the receiver operating characteristics curve and correlations between the change scores. MIC was assessed using the optimal cutoff point at the receiver operating characteristics curve. Results Area under the receiver operating characteristics curve estimates were 0.96 (95% confidence interval [CI] 0.91,1.00) for OSS, 0.82 (95% CI 0.66,0.99) for EQ-5D 5-level utility index, 0.73 (95% CI 0.58,0.87) for EQ visual analogue scale, and 0.74 (95% CI 0.58,0.90) for FABQ-PA. MIC were 6.0 points for OSS, 0.024 points for EQ-5D 5-level utility index, 10.0 points for EQ visual analogue scale, and -5.0 points for FABQ-PA. Conclusion Responsiveness of the OSS, EQ-5D, and FABQ-PA was sufficient to measure improvement after arthroscopic decompression surgery.
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Cook JA, Baldwin M, Cooper C, Nagra NS, Crocker JC, Glaze M, Greenall G, Rangan A, Kottam L, Rees JL, Farrar-Hockley D, Merritt N, Hopewell S, Beard D, Thomas M, Dritsaki M, Carr AJ. Findings from the patch augmented rotator cuff surgery (PARCS) feasibility study. Pilot Feasibility Stud 2021; 7:163. [PMID: 34416915 PMCID: PMC8377837 DOI: 10.1186/s40814-021-00899-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 08/06/2021] [Indexed: 01/08/2023] Open
Abstract
Background A rotator cuff tear is a common disabling shoulder problem. Symptoms include pain, weakness, lack of mobility and sleep disturbance. Many patients require surgery to repair the tear; however, there is a high failure rate. There is a pressing need to improve the outcome of rotator cuff surgery. The use of patch augmentation to provide support to the healing process and improve patient outcomes holds new promise. Different materials (e.g. human/animal skin or intestine tissue, and completely synthetic materials) and processes (e.g. woven or a mesh) have been used to produce patches. However, clinical evidence on their use is limited. The patch augmented rotator cuff surgery (PARCS) feasibility study aimed to determine the design of a definitive randomised controlled trial (RCT) assessing the effectiveness and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and feasible. Methods A mixed methods feasibility study of conducing a subsequent RCT. The project involved six stages: a systematic review of clinical evidence; a survey of the British Elbow and Shoulder Society’s (BESS) surgical membership; a survey of surgeon trialists; focus groups and interviews with stakeholders; a two-round Delphi study administered via online questionnaires and a 2-day consensus meeting. Results The BESS surgeons’ survey identified a variety of patches in use (105 (21%) responses received). Twenty-four surgeons (77%) completed the trialist survey relating to trial design. Four focus groups were conducted involving 24 stakeholders. Twenty-nine (67% of invited) individuals took part in the Delphi. Differing views were held on a number of aspects including the appropriate patient population for trial participation. Agreement on the key research questions and the outline of two potential RCTs were achieved through the Delphi study and the consensus meeting. Conclusions Randomised comparisons of on-lay patch use for completed rotator cuff repairs, and bridging patch use for partial rotator cuff repairs were identified as areas for further research. The value of an observational study to assess safety concerns of patch use was also highlighted. The main limitation was that the findings were influenced by the participants, who might not necessarily reflect all stakeholders.
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Affiliation(s)
- Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Mathew Baldwin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Navraj S Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joanna C Crocker
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.,National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK
| | - Molly Glaze
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Gemma Greenall
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,The James Cook University Hospital, South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | - Lucksy Kottam
- The James Cook University Hospital, South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | - Jonathan L Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Dair Farrar-Hockley
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Naomi Merritt
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Melina Dritsaki
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Gianola S, Iannicelli V, Fascio E, Andreano A, Li LC, Valsecchi MG, Moja L, Castellini G. Kinesio taping for rotator cuff disease. Cochrane Database Syst Rev 2021; 8:CD012720. [PMID: 34365646 PMCID: PMC8406708 DOI: 10.1002/14651858.cd012720.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Kinesio Taping (KT) is one of the conservative treatments proposed for rotator cuff disease. KT is an elastic, adhesive, latex-free taping made from cotton, without active pharmacological agents. Clinicians have adopted it in the rehabilitation treatment of painful conditions, however, there is no firm evidence on its benefits. OBJECTIVES To determine the benefits and harms of KT in adults with rotator cuff disease. SEARCH METHODS We searched the Cochrane Library, MEDLINE, Embase, PEDro, CINAHL, Clinicaltrials.gov and WHO ICRTP registry to July 27 2020, unrestricted by date and language. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials (RCTs) including adults with rotator cuff disease. Major outcomes were overall pain, function, pain on motion, active range of motion, global assessment of treatment success, quality of life, and adverse events. DATA COLLECTION AND ANALYSIS We used standard methodologic procedures expected by Cochrane. MAIN RESULTS We included 23 trials with 1054 participants. Nine studies (312 participants) assessed the effectiveness of KT versus sham therapy and fourteen studies (742 participants) assessed the effectiveness of KT versus conservative treatment. Most participants were aged between 18 and 50 years. Females comprised 52% of the sample. For the meta-analysis, we considered the last available measurement within 30 days from the end of the intervention. All trials were at risk of performance, selection, reporting, attrition, and other biases. Comparison with sham taping Due to very low-certainty evidence, we are uncertain whether KT improves overall pain, function, pain on motion and active range of motion compared with sham taping. Mean overall pain (0 to 10 scale, 0 no pain) was 2.96 points with sham taping and 3.03 points with KT (3 RCTs,106 participants), with an absolute difference of 0.7% worse, (95% CI 7.7% better to 9% worse) and a relative difference of 2% worse (95% CI 21% better to 24% worse) at four weeks. Mean function (0 to 100 scale, 0 better function) was 47.1 points with sham taping and 39.05 points with KT (6 RCTs, 214 participants), with an absolute improvement of 8% (95% CI 21% better to 5% worse)and a relative improvement of 15% (95% CI 40% better to 9% worse) at four weeks. Mean pain on motion (0 to 10 scale, 0 no pain) was 4.39 points with sham taping and 2.91 points with KT even though not clinically important (4 RCTs, 153 participants), with an absolute improvement of 14.8% (95% CI 22.5% better to 7.1% better) and a relative improvement of 30% (95% CI 45% better to 14% better) at four weeks. Mean active range of motion (shoulder abduction) without pain was 174.2 degrees with sham taping and 184.43 degrees with KT (2 RCTs, 68 participants), with an absolute improvement of 5.7% (95% CI 8.9% worse to 20.3% better) and a relative improvement of 6% (95% CI 10% worse to 22% better) at two weeks. No studies reported global assessment of treatment success. Quality of life was reported by one study but data were disaggregated in subscales. No reliable estimates for adverse events (4 studies; very low-certainty) could be provided due to the heterogeneous description of events in the sample. Comparison with conservative treatments Due to very low-certainty evidence, we are uncertain if KT improves overall pain, function, pain on motion and active range of motion compared with conservative treatments. However, KT may improve quality of life (low certainty of evidence). Mean overall pain (0 to 10 scale, 0 no pain) was 0.9 points with conservative treatment and 0.46 points with KT (5 RCTs, 266 participants), with an absolute improvement of 4.4% (95% CI 13% better to 4.6% worse) and a relative improvement of 15% (95% CI 46% better to 16% worse) at six weeks. Mean function (0 to 100 scale, 0 better function) was 46.6 points with conservative treatment and 33.47 points with KT (14 RCTs, 499 participants), with an absolute improvement of 13% (95% CI 24% better to 2% better) and a relative improvement of 18% (95% CI 32% better to 3% better) at four weeks. Mean pain on motion (0 to 10 scale, 0 no pain) was 4 points with conservative treatment and 3.94 points with KT (6 RCTs, 225 participants), with an absolute improvement of 0.6% (95% CI 7% better to 8% worse) and a relative improvement of 1% (95% CI 12% better to 10% worse) at four weeks. Mean active range of motion (shoulder abduction) without pain was 156.6 degrees with conservative treatment and 159.64 degrees with KT (3 RCTs, 143 participants), with an absolute improvement of 3% (95% CI 11% worse to 17 % better) and a relative improvement of 3% (95% CI 9% worse to 14% better) at six weeks. Mean of quality of life (0 to 100, 100 better quality of life) was 37.94 points with conservative treatment and 56.64 points with KT (1 RCTs, 30 participants), with an absolute improvement of 18.7% (95% CI 14.48% better to 22.92% better) and a relative improvement of 53% (95% CI 41% better to 65% better) at four weeks. No studies were found for global assessment of treatment success. No reliable estimates for adverse events (7 studies, very low certainty of evidence) could be provided due to the heterogeneous description of events in the whole sample. AUTHORS' CONCLUSIONS Kinesio taping for rotator cuff disease has uncertain effects in terms of self-reported pain, function, pain on motion and active range of motion when compared to sham taping or other conservative treatments as the certainty of evidence was very low. Low-certainty evidence shows that kinesio taping may improve quality of life when compared to conservative treatment. We downgraded the evidence for indirectness due to differences among co-interventions, imprecision due to small number of participants across trials as well as selection bias, performance and detection bias. Evidence on adverse events was scarce and uncertain. Based upon the data in this review, the evidence for the efficacy of KT seems to demonstrate little or no benefit.
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Affiliation(s)
- Silvia Gianola
- Unit of Clinical Epidemiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | - Valerio Iannicelli
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milano, Italy
| | | | - Anita Andreano
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Linda C Li
- Department of Physical Therapy, University of British Columbia, Richmond, Canada
| | - Maria Grazia Valsecchi
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Lorenzo Moja
- Unit of Clinical Epidemiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Greta Castellini
- Unit of Clinical Epidemiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
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10
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Cook JA, Baldwin M, Cooper C, Nagra NS, Crocker JC, Glaze M, Greenall G, Rangan A, Kottam L, Rees JL, Farrar-Hockley D, Merritt N, Hopewell S, Beard D, Thomas M, Dritsaki M, Carr AJ. Patch augmentation surgery for rotator cuff repair: the PARCS mixed-methods feasibility study. Health Technol Assess 2021; 25:1-138. [PMID: 33646096 PMCID: PMC7958078 DOI: 10.3310/hta25130] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND A rotator cuff tear is a common, disabling shoulder problem. Symptoms may include pain, weakness, lack of shoulder mobility and sleep disturbance. Many patients require surgery to repair the tear; however, there is a high failure rate. There is a need to improve the outcome of rotator cuff surgery, and the use of patch augmentation (on-lay or bridging) to provide support to the healing process and improve patient outcomes holds promise. Patches have been made using different materials (e.g. human/animal skin or tissue and synthetic materials) and processes (e.g. woven or mesh). OBJECTIVES The aim of the Patch Augmented Rotator Cuff Surgery (PARCS) feasibility study was to determine the design of a definitive randomised controlled trial assessing the clinical effectiveness and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and feasible. DESIGN A mixed-methods feasibility study of a randomised controlled trial. DATA SOURCES MEDLINE, EMBASE and the Cochrane Library databases were searched between April 2006 and August 2018. METHODS The project involved six stages: a systematic review of clinical evidence, a survey of the British Elbow and Shoulder Society's surgical membership, a survey of surgeon triallists, focus groups and interviews with stakeholders, a two-round Delphi study administered via online questionnaires and a 2-day consensus meeting. The various stakeholders (including patients, surgeons and industry representatives) were involved in stages 2-6. RESULTS The systematic review comprised 52 studies; only 15 were comparative and, of these, 11 were observational (search conducted in August 2018). These studies were typically small (median number of participants 26, range 5-152 participants). There was some evidence to support the use of patches, although most comparative studies were at a serious risk of bias. Little to no published clinical evidence was available for a number of patches in clinical use. The membership survey of British Elbow and Shoulder surgeons [105 (21%) responses received] identified a variety of patches in use. Twenty-four surgeons (77%) completed the triallist survey relating to trial design. Four focus groups were conducted, involving 24 stakeholders. Differing views were held on a number of aspects of trial design, including the appropriate patient population (e.g. patient age) to participate. Agreement on the key research questions and the outline of two potential randomised controlled trials were achieved through the Delphi study [29 (67%)] and the consensus meeting that 22 participants attended. LIMITATIONS The main limitation was that the findings were influenced by the participants, who are not necessarily representative of the views of the relevant stakeholder groups. CONCLUSION The need for further clinical studies was clear, particularly given the range and number of different patches available. FUTURE WORK Randomised comparisons of on-lay patch use for completed rotator cuff repairs and bridging patch use for partial rotator cuff repairs were identified as areas for further research. The value of an observational study to assess safety concerns of patch use was also highlighted. These elements are included in the trial designs proposed in this study. STUDY REGISTRATION The systematic review is registered as PROSPERO CRD42017057908. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 13. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mathew Baldwin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Navraj S Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joanna C Crocker
- Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
| | - Molly Glaze
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Gemma Greenall
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amar Rangan
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Lucksy Kottam
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Jonathan L Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Dair Farrar-Hockley
- Patient representative, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Naomi Merritt
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Melina Dritsaki
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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11
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Chaler J, Louati H, Uhthoff HK, Trudel G. Supraspinatus tendon transosseous vs anchor repair surgery: a comparative study of mechanical recovery in the rabbit. J Orthop Surg Res 2020; 15:585. [PMID: 33287832 PMCID: PMC7720526 DOI: 10.1186/s13018-020-02085-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/10/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Supraspinatus (SSP) tendon ruptures requiring surgical repair are common. Arthroscopic suture anchor fixation has gradually replaced transosseous repair in supraspinatus tendon tear. Our objective was to compare mechanical properties between transosseous and anchor supraspinatus repair in the first 6 postoperative weeks in a rabbit model. METHODS One hundred and fifty-two rabbits had one supraspinatus tendon repaired either with an anchor suture 1 week after detachment or with transosseous sutures. Rabbits were euthanized at 0, 1, 2, 4 or 6 postoperative weeks. Experimental and contralateral tendons (304 tendons) were mechanically tested to failure. Data are expressed as percent of contralateral. RESULTS Anchor repair had higher loads to failure compared to transosseous repair, at immediate repair (week 0, 52 ± 21% vs 25 ± 17%, respectively; p = 0.004) and at 1 postoperative week (64 ± 32% vs 28 ± 10%; p = 0.003) with no difference after 2 weeks. There was no difference in stiffness. Transosseous repairs showed higher rates of midsubstance failures compared to anchor repairs at 1 (p = 0.004) and 2 postoperative weeks (p < 0.001). Both transosseous and anchor repairs restored supraspinatus mechanical properties after 4 postoperative weeks. CONCLUSION Anchor repair provided better initial tensile strength while transosseous repair led to a faster normalization (namely, midsubstance) of the mode of failure. Research to optimize supraspinatus repair may need to consider the advantages from both surgical approaches.
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Affiliation(s)
- Joaquim Chaler
- Department of Physical Medicine and Rehabilitation, Egarsat, Terrassa, Barcelona, Spain.,Escola Universitaria de Salut i Esport, Universitat de Girona-Universitat de Barcelona, Campus Bellvitge, Hospitalet, Barcelona, Spain
| | - Hakim Louati
- Bone and Joint Research Laboratory, The Ottawa Hospital Research Institute, 451 Smyth Road, Ottawa, Ontario, K1H 5M2, Canada.,Division of Orthopedic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Hans K Uhthoff
- Bone and Joint Research Laboratory, The Ottawa Hospital Research Institute, 451 Smyth Road, Ottawa, Ontario, K1H 5M2, Canada.,Division of Orthopedic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Guy Trudel
- Bone and Joint Research Laboratory, The Ottawa Hospital Research Institute, 451 Smyth Road, Ottawa, Ontario, K1H 5M2, Canada. .,Division of Physical Medicine and Rehabilitation, Department of Medicine, Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Canada.
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12
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Baldwin M, Nagra NS, Greenall G, Carr AJ, Beard D, Rees JL, Rangan A, Merritt N, Dritsaki M, Hopewell S, Cook JA. Use of implantable meshes for augmented rotator cuff repair: a systematic review and meta-analysis. BMJ Open 2020; 10:e039552. [PMID: 33293307 PMCID: PMC7722806 DOI: 10.1136/bmjopen-2020-039552] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 09/03/2020] [Accepted: 10/14/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To appraise studies reporting on clinical effectiveness and safety of surgical meshes used to augment rotator cuff repairs (RCRs). DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE, Embase and Cochrane databases were searched between April 2006 and April 2020. ELIGIBILITY CRITERIA All studies evaluating adults (≥18 years) undergoing RCR were considered. There were no language restrictions. DATA EXTRACTION AND SYNTHESIS Screening, data extraction and quality appraisal were conducted by two independent reviewers. Meta-analysis was conducted using a random-effects models if ≥2 comparative studies reported the same outcome measure. Risk of bias assessment was undertaken for randomised (RoB2, Cochrane) and comparative studies (ROBINS-I, Cochrane). RESULTS We included 60 studies, consisting of 7 randomised controlled trials, 13 observational comparative studies and 40 observational case series. All comparative studies reported on shoulder-specific functional outcome scores, 18 on the radiographic occurrence of re-tear and 14 on pain score metrics. All studies contained some risk of bias.Compared with non-augmented repair, a small improvement in shoulder-specific function or pain scores was observed for synthetic patches with a mean improvement of 6.7 points on the University of California Los Angles (UCLA) shoulder score (95% CI 0.1 to 13.4) and 0.46 point reduction on the Visual Analogue Scale (95% CI -0.74 to -0.17), respectively. A reduced likelihood of radiologically observed re-tear was observed for synthetic (risk ratio (RR) 0.41, 95% CI 0.27 to 0.61) and allograft (RR 0.34, 95% CI 0.18 to 0.65) patches. A total of 49 studies reported on the occurrence of complications. Slightly higher crude complication rates were observed following patch-augmented repair (2.1%) than standard repair (1.6%). CONCLUSIONS While several studies suggest a decreased failure rate and small improvements in shoulder function and pain following augmented RCR, a paucity of rigorous clinical evaluation, for both effectiveness and safety, prevents firm recommendations. PROSPERO REGISTRATION NUMBER CRD42017057908.
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Affiliation(s)
- Mathew Baldwin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - N S Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Gemma Greenall
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - J L Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
- Department of Orthopaedics, James Cook University Hospital, Middlesbrough, Middlesbrough, UK
| | - Naomi Merritt
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Melina Dritsaki
- Centre for Statistics in Medicine, Oxford University, Oxford, Oxfordshire, UK
| | - Sally Hopewell
- Centre for Statistics in Medicine, Oxford University, Oxford, Oxfordshire, UK
| | - Jonathan Alistair Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
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13
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Lee JH, Haen PS, Lam PH, Tan M, Murrell GA. Comparing clinical outcomes between rotator cuff repairs, SLAP repairs, and combined repairs. JSES Int 2020; 4:875-881. [PMID: 33345228 PMCID: PMC7738600 DOI: 10.1016/j.jseint.2020.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Superior labrum lesion from anterior to posterior (SLAP) often presents together with other shoulder pathologies such as rotator cuff tear (RCT), but it is uncertain if repairing both SLAP and RCT has superior clinical outcomes over isolated repairs of SLAP and RCT. MATERIALS AND METHODS This was a retrospective cohort study with prospectively collected data, reviewing 157 patients who underwent arthroscopic repair of either RCT, SLAP (type II lesion), or both. Before surgery and after 6 weeks, 12 weeks, and 24 weeks, shoulder objective range of motion and strength were measured, patient-reported function and pain was assessed by the modified L'Insalata questionnaire with a Likert scale, and complications after each repair were examined. RESULTS At 24 weeks after surgery, the combined group (n = 22) and SLAP group (n = 47) had significantly higher forward flexion (165° ± 4° and 167° ± 4° vs. 154° ± 3°, P = .01 and P = .01), external rotation strength (82 ± 6 N, 81 ± 6 N vs. 61 ± 3 N, P = .01 and P = .01), and abduction strength (94 ± 14 N, 78 ± 8 N vs. 53 ± 3 N, P = .001 and P = .02) compared with the rotator cuff tear repair (RCR) group (n = 88). The combined group also had stronger internal rotation than the RCR group (107 ± 12 N vs. 72 ± 4 N, P = .02). Function and pain improved from "severe-moderate" to "moderate-mild" in all groups after surgery. CONCLUSION Repairing RCT and SLAP tears together results in significant clinical benefits compared to repairing just RCT and analogous results against SLAP-only repair.
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Affiliation(s)
- Jae H.T. Lee
- Orthopaedic Research Institute, St. George Hospital Campus, University of New South Wales, Sydney, NSW, Australia
| | - Pieter S.W. Haen
- Orthopaedic Research Institute, St. George Hospital Campus, University of New South Wales, Sydney, NSW, Australia
| | - Patrick H. Lam
- Orthopaedic Research Institute, St. George Hospital Campus, University of New South Wales, Sydney, NSW, Australia
| | - Martin Tan
- Orthopaedic Research Institute, St. George Hospital Campus, University of New South Wales, Sydney, NSW, Australia
| | - George A.C. Murrell
- Orthopaedic Research Institute, St. George Hospital Campus, University of New South Wales, Sydney, NSW, Australia
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14
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Yang FA, Liao CD, Wu CW, Shih YC, Wu LC, Chen HC. Effects of applying platelet-rich plasma during arthroscopic rotator cuff repair: a systematic review and meta-analysis of randomised controlled trials. Sci Rep 2020; 10:17171. [PMID: 33057143 PMCID: PMC7560855 DOI: 10.1038/s41598-020-74341-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 09/25/2020] [Indexed: 02/07/2023] Open
Abstract
Because of its healing properties, platelet-rich plasma (PRP) has been applied to the bone-tendon interface during arthroscopic rotator cuff repair to improve surgical outcomes. However, its effects remain ambiguous. Therefore, we conducted this systematic review and meta-analysis to assess the effects of PRP on retear rate and functional outcomes. Randomised control trials were identified and extracted. Data collection was completed on 15 February 2020. The results are expressed as the risk ratio (RR) for the categorical variables and weighted mean difference for the continuous variables, with 95% confidence intervals (CIs). Analyses were performed using RevMan 5.3 software. Seven randomised controlled trials published from 2013 to 2018, with 541 patients in total, were included. The results revealed a significant decrease in retear rate [RR 0.38, 95% CI (0.22, 0.68), P = 0.0009). Furthermore, a significant improvement was observed regarding short-term Constant score [mean difference = 3.28, 95% CI (1.46, 5.11), P = 0.0004), short-term University of California at Los Angeles activity score [mean difference = 1.60, 95% CI (0.79, 2.42), P = 0.0001], and short-term visual analogue scale score [mean difference = - 0.14, 95% CI (- 0.23, - 0.05), P = 0.002]. This systematic review indicates the efficacy of PRP when applied to the bone-tendon interface during arthroscopic rotator cuff repair.
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Affiliation(s)
- Fu-An Yang
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chun-De Liao
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, No. 291 Jhongjheng Road, Jhonghe District, New Taipei City, 235, Taiwan
- School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chin-Wen Wu
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, No. 291 Jhongjheng Road, Jhonghe District, New Taipei City, 235, Taiwan
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ya-Chu Shih
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Lien-Chen Wu
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Hung-Chou Chen
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, No. 291 Jhongjheng Road, Jhonghe District, New Taipei City, 235, Taiwan.
- Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
- Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.
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15
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Brindisino F, Ristori D, Lorusso M, Miele S, Pellicciari L, Rossettini G, Bonetti F, Heick JD, Testa M. Subacromial impingement syndrome: a survey of Italian physiotherapists and orthopaedics on diagnostic strategies and management modalities. Arch Physiother 2020; 10:16. [PMID: 32905154 PMCID: PMC7465722 DOI: 10.1186/s40945-020-00087-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/29/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND AIM The subacromial impingement syndrome (SIS) represents a common cause of disability in approximately 74% of patients with Shoulder Pain (SP). Even if contemporary research suggests that this mechanism is not (always) the dominant driver in SP, SIS is still a source of debate among scholars and clinicians. From a clinical point of view, evidence has suggested that clinicians can use both medical and physiotherapy approaches as effective methods to treat SIS.This survey aims to investigate models of management of patients with SIS in a sample of Italian physiotherapist specialists (Orthopaedic Manipulative Physical Therapists, -OMPTs-) and orthopaedic surgeons. MATERIALS AND METHODS An online survey with 29-item questionnaire was administered to assess the knowledge of OMPTs and orthopaedic surgeons about: a) strategies of clinical examination; b) the role of imaging in the diagnostic process; c) the physiotherapy management; and d) the pharmacological and surgical management in patients with SIS. RESULTS Six-hundred and twenty-nine respondents completed the survey (511 OMPTs (79.97%) and 128 orthopaedic surgeons (20.03%)). Ninety-two percent (n = 470) of the OMPTs and 80.5% (n = 103) of orthopaedic surgeons stated that in patients with SIS, a combination of diagnostic tests produced better accuracy (p = < 0.001). Twenty point seven % of OMPTs (n = 106) and 4.7% of orthopaedic surgeon (n = 6) stated that the Lift off was the most specific test (p = < 0.001). Four-hundred-and-twenty-four OMPTs (83%) and 40 orthopaedic surgeons (31.3%) answered that the gold standard for diagnosis of a patient with SIS are history and clinical examination (p < 0.001). CONCLUSION OMPTs and orthopaedic surgeons approach patients with SIS differently during both the assessment and the treatment. OMPTs appear to be appropriate in planning and managing clinical examination and therapeutic strategies to use with patients with SIS.
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Affiliation(s)
- Fabrizio Brindisino
- Department of Medicine and Health Science “Vincenzo Tiberio”, University of Molise C/da Tappino c/o Cardarelli Hospital, 86100 Campobasso, Italy
- Department of Clinical Sciences and Translational Medicine, Tor Vergata University of Rome, Rome, Italy
| | - Diego Ristori
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health – University of Genova – Campus of Savona, Savona, Italy
| | - Mariangela Lorusso
- Department of Clinical Sciences and Translational Medicine, Tor Vergata University of Rome, Rome, Italy
| | - Simone Miele
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health – University of Genova – Campus of Savona, Savona, Italy
| | | | - Giacomo Rossettini
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health – University of Genova – Campus of Savona, Savona, Italy
| | - Francesca Bonetti
- Department of Clinical Sciences and Translational Medicine, Tor Vergata University of Rome, Rome, Italy
| | - John Duane Heick
- Department of Physical Therapy and Athletic Training, Northern Arizona University Flagstaff, Flagstaff, AZ USA
| | - Marco Testa
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health – University of Genova – Campus of Savona, Savona, Italy
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16
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Nazari G, MacDermid JC, Bobos P. Conservative versus Surgical Interventions for Shoulder Impingement: An Overview of Systematic Reviews of Randomized Controlled Trials. Physiother Can 2020; 72:282-297. [PMID: 35110797 DOI: 10.3138/ptc-2018-0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: Numerous systematic reviews (SRs) of randomized controlled trials (RCTs) have emerged that investigate the effectiveness of conservative (supervised exercises) versus surgical (arthroscopic subacromial decompression) interventions for patients with shoulder impingement; however, there are disparities in the quality of the evidence synthesized. The purpose of this study was to conduct an overview of SRs of RCTs to critically appraise the evidence and establish the current state of effectiveness of conservative versus surgical interventions on clinical outcomes among patients with shoulder impingement. Method: The MEDLINE, EMBASE, CINAHL, and PubMed electronic databases were searched for January 2008 to September 2018, and we found SRs of RCTs of patients with shoulder impingement, subacromial pain syndrome, or subacromial impingement syndrome who had received conservative versus surgical interventions to improve outcomes. Two authors extracted the data, and two independent review authors assessed the risk of bias and quality. Results: A total of 15 SRs were identified. One was rated as high quality, 7 as moderate quality, 5 as low quality, and 2 as critically low quality. The results were in line with one another, indicating that no differences in outcomes existed between conservative and surgical interventions among patients with shoulder impingement. Conclusion: There were no clinically important or statistically significant differences in outcomes between conservative versus surgical interventions among patients with subacromial impingement syndrome. To enhance clinical outcomes in this patient population, shoulder-specific exercises that aim to improve muscle strength and flexibility must be considered as the first line of conservative treatment.
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Affiliation(s)
- Goris Nazari
- School of Physical Therapy, Faculty of Health Sciences.,Collaborative Program in Musculoskeletal Health Research, Bone and Joint Institute, Western University
| | - Joy C MacDermid
- School of Physical Therapy, Faculty of Health Sciences.,Collaborative Program in Musculoskeletal Health Research, Bone and Joint Institute, Western University.,Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ont
| | - Pavlos Bobos
- School of Physical Therapy, Faculty of Health Sciences.,Collaborative Program in Musculoskeletal Health Research, Bone and Joint Institute, Western University
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17
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Jones AM, Koehoorn M, Mcleod CB. Gender Differences in Surgery for Work-Related Musculoskeletal Injury: A Population-Based Cohort Study. ACTA ACUST UNITED AC 2020; 15:47-62. [PMID: 32176610 PMCID: PMC7075441 DOI: 10.12927/hcpol.2020.26131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The objective of this study is to examine if women are less likely than men to receive surgery following work-related musculoskeletal injury in the Canadian province of British Columbia. METHODS The study included 2,403 workers with work-related knee meniscal tear, thoracic/lumbar disc displacement or rotator cuff tear. Probability of surgery was compared by gender using Kaplan-Meier methods and Cox proportional hazards models. RESULTS For each injury type, a smaller proportion of women received surgery compared to men (knee: 76% vs. 80%; shoulder: 13% vs. 36%; back: 13% vs. 19%). In adjusted models, compared to men, women were 0.87 (95% confidence interval [CI] [0.69, 1.09]), 0.35 (95% CI [0.25, 0.48]) and 0.54 (95% CI [0.31, 0.95]) times less likely to receive knee, shoulder or back surgery, respectively. CONCLUSIONS Probability of surgery following work-related musculoskeletal injury was lower for women than for men. Strategies to ensure gender equitable delivery of surgical services by workers' compensation systems may be warranted, although further research is necessary to investigate determinants of the gender difference and the impact of elective orthopaedic surgery on occupational outcomes.
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Affiliation(s)
- Andrea M Jones
- School of Population and Public Health, University of British Columbia, Vancouver, BC
| | - Mieke Koehoorn
- Professor, School of Population and Public Health, University of British Columbia, Vancouver, BC
| | - Christopher B Mcleod
- Associate Professor, School of Population and Public Health, University of British Columbia, Vancouver, BC, Scientist, Institute for Work and Health, University Avenue, Toronto, ON
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18
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Cleland T, Jain NB, Chae J, Hansen KM, Hisel TZ, Gunzler DD, Whitehair VC, Kim CH, Wilson RD. The protocol for a multisite, double blind, randomized, placebo-controlled trial of axillary nerve stimulation for chronic shoulder pain. Trials 2020; 21:248. [PMID: 32143732 PMCID: PMC7059286 DOI: 10.1186/s13063-020-4174-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 02/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Shoulder impingement syndrome is one of the most common causes of shoulder pain, accounting for approximately 30% of all shoulder pain. Approximately 35% of patients with shoulder impingement syndrome are refractory to conservative treatment. For patients who fail conservative treatment, there is no established treatment to successfully treat their chronic pain. Prior randomized control trials have demonstrated efficacy for the use of a single lead intramuscular peripheral nerve stimulation of the axillary nerve at the motor points of the deltoid muscle for treatment of hemiplegic shoulder pain. This is the first controlled trial to utilize the same novel technology to treat shoulder impingement syndrome outside of the stroke population. METHODS This is a dual-site, placebo-controlled, double-blinded, randomized control trial. Participants will be randomized to two treatment groups. The intervention group will be treated with active peripheral nerve stimulation of the axillary nerve of the affected shoulder and the control group will be treated with sham peripheral nerve stimulation of the axillary nerve of the affected shoulder. Both groups will receive a standardized exercise therapy program directed by a licensed therapist. DISCUSSION This study protocol will allow the investigators to determine if this novel, non-pharmacologic treatment of shoulder pain can demonstrate the same benefit in musculoskeletal patients which has been previously demonstrated in the stroke population. TRIAL REGISTRATION Clinicaltrials.gov, NCT03752619. Registered on 26 November 2018.
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Affiliation(s)
- Travis Cleland
- MetroHealth Rehabilitation Institute, MetroHealth System, 4229 Pearl Rd, N5-27, Cleveland, OH 44109 USA
| | - Nitin B. Jain
- Vanderbilt University Medical Center, 3319 West End Ave, Nashville, TN 37203 USA
| | - John Chae
- MetroHealth Rehabilitation Institute, MetroHealth System, 4229 Pearl Rd, N5-27, Cleveland, OH 44109 USA
| | - Kristine M. Hansen
- MetroHealth Rehabilitation Institute, MetroHealth System, 4229 Pearl Rd, N5-27, Cleveland, OH 44109 USA
| | - Terri Z. Hisel
- MetroHealth Rehabilitation Institute, MetroHealth System, 4229 Pearl Rd, N5-27, Cleveland, OH 44109 USA
| | - Douglas D. Gunzler
- Center for Healthcare Research and Policy, MetroHealth System, 2500 MetroHealth Dr., Cleveland, OH 44109 USA
| | - Victoria C. Whitehair
- MetroHealth Rehabilitation Institute, MetroHealth System, 4229 Pearl Rd, N5-27, Cleveland, OH 44109 USA
| | - Chong H. Kim
- MetroHealth Rehabilitation Institute, MetroHealth System, 4229 Pearl Rd, N5-27, Cleveland, OH 44109 USA
| | - Richard D. Wilson
- MetroHealth Rehabilitation Institute, MetroHealth System, 4229 Pearl Rd, N5-27, Cleveland, OH 44109 USA
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Epidemiology of tendon and ligament injuries in Aotearoa/New Zealand between 2010 and 2016. Inj Epidemiol 2020; 7:5. [PMID: 32127040 PMCID: PMC7008565 DOI: 10.1186/s40621-020-0231-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 01/03/2020] [Indexed: 01/05/2023] Open
Abstract
Background Injuries to tendons and ligaments make up a large portion of musculoskeletal injuries, and contribute to significant morbidity and healthcare costs. However, there is currently a poor understanding of the burden of these injuries at a population level. The purpose of this study was to quantify the burden and distribution of tendon and ligament injuries in the Aotearoa/New Zealand population. Methods Using the Accident Compensation Corporation (ACC, a no fault comprehensive compensation scheme encompassing all of Aotearoa/New Zealand; population in 2013 4.4 million) database, data specific to tendon and ligament injuries were identified between July 2010 and June 2016. The total number of claims made and the total cost of these claims per financial year were analyzed. Injuries were categorized by anatomical site, gender, ethnicity and age of the claimant. Results During the 6-year study period, the total number of tendon and ligament injury claims was 1,112,077, with a total cost of over $1.4 billion NZD. There was a 16.2% increase in the number of claims, and a 40% increase in the total cost of these injuries during this period. The majority of claims were made by people of European ethnicity, whilst the number of claims made by people of Asian ethnicity increased at the greatest rate; 52% (from 9047 claims in 2011) during the 6-year study period. Interestingly, Māori (Indigenous New Zealanders) maintained the highest average cost per claim ($1614.05 NZD); 13% more than the overall average cost per claim ($1262.12 NZD). The most common sites of injury were the shoulder and knee; these injuries were also the greatest contributors to overall cost. The total costs of injuries peaked in claimants aged 40–54, irrespective of the number of claims made for that age group. Conclusions Health and economic burdens of tendon and ligament injuries in Aotearoa/New Zealand are rising. The high healthcare costs underscore the urgent need for multifaceted interventions to reduce the incidence and improve clinical outcomes of tendon and ligament injuries.
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Karjalainen TV, Jain NB, Heikkinen J, Johnston RV, Page CM, Buchbinder R. Surgery for rotator cuff tears. Cochrane Database Syst Rev 2019; 12:CD013502. [PMID: 31813166 PMCID: PMC6900168 DOI: 10.1002/14651858.cd013502] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND This review is one in a series of Cochrane Reviews of interventions for shoulder disorders. OBJECTIVES To synthesise the available evidence regarding the benefits and harms of rotator cuff repair with or without subacromial decompression in the treatment of rotator cuff tears of the shoulder. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and WHO ICRTP registry unrestricted by date or language until 8 January 2019. SELECTION CRITERIA Randomised controlled trials (RCTs) including adults with full-thickness rotator cuff tears and assessing the effect of rotator cuff repair compared to placebo, no treatment, or any other treatment were included. As there were no trials comparing surgery with placebo, the primary comparison was rotator cuff repair with or without subacromial decompression versus non-operative treatment (exercises with or without glucocorticoid injection). Other comparisons were rotator cuff repair and acromioplasty versus rotator cuff repair alone, and rotator cuff repair and subacromial decompression versus subacromial decompression alone. Major outcomes were mean pain, shoulder function, quality of life, participant-rated global assessment of treatment success, adverse events and serious adverse events. The primary endpoint for this review was one year. DATA COLLECTION AND ANALYSIS We used standard methodologic procedures expected by Cochrane. MAIN RESULTS We included nine trials with 1007 participants. Three trials compared rotator cuff repair with subacromial decompression followed by exercises with exercise alone. These trials included 339 participants with full-thickness rotator cuff tears diagnosed with magnetic resonance imaging (MRI) or ultrasound examination. One of the three trials also provided up to three glucocorticoid injections in the exercise group. All surgery groups received tendon repair with subacromial decompression and the postoperative exercises were similar to the exercises provided for the non-operative groups. Five trials (526 participants) compared repair with acromioplasty versus repair alone; and one trial (142 participants) compared repair with subacromial decompression versus subacromial decompression alone. The mean age of trial participants ranged between 56 and 68 years, and females comprised 29% to 56% of the participants. Symptom duration varied from a mean of 10 months up to 28 months. Two trials excluded tears with traumatic onset of symptoms. One trial defined a minimum duration of symptoms of six months and required a trial of conservative therapy before inclusion. The trials included mainly repairable full-thickness supraspinatus tears, six trials specifically excluded tears involving the subscapularis tendon. All trials were at risk of bias for several criteria, most notably due to lack of participant and personnel blinding, but also for other reasons such as unclearly reported methods of random sequence generation or allocation concealment (six trials), incomplete outcome data (three trials), selective reporting (six trials), and other biases (six trials). Our main comparison was subacromial decompression versus non-operative treatment and results are reported for the 12 month follow up. At one year, moderate-certainty evidence (downgraded for bias) from 3 trials with 258 participants indicates that surgery probably provides little or no improvement in pain; mean pain (range 0 to 10, higher scores indicate more pain) was 1.6 points with non-operative treatment and 0.87 points better (0.43 better to 1.30 better) with surgery.. Mean function (zero to 100, higher score indicating better outcome) was 72 points with non-operative treatment and 6 points better (2.43 better to 9.54 better) with surgery (3 trials; 269 participants), low-certainty evidence (downgraded for bias and imprecision). Participant-rated global success rate was 873/1000 after non-operative treatment and 943/1000 after surgery corresponding to (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.96 to 1.22; low-certainty evidence (downgraded for bias and imprecision). Health-related quality of life was 57.5 points (SF-36 mental component score, 0 to 100, higher score indicating better quality of life) with non-operative treatment and 1.3 points worse (4.5 worse to 1.9 better) with surgery (1 trial; 103 participants), low-certainty evidence (downgraded for bias and imprecision). We were unable to estimate the risk of adverse events and serious adverse events as only one event was reported across the trials (very low-certainty evidence; downgraded once due to bias and twice due to very serious imprecision). AUTHORS' CONCLUSIONS At the moment, we are uncertain whether rotator cuff repair surgery provides clinically meaningful benefits to people with symptomatic tears; it may provide little or no clinically important benefits with respect to pain, function, overall quality of life or participant-rated global assessment of treatment success when compared with non-operative treatment. Surgery may not improve shoulder pain or function compared with exercises, with or without glucocorticoid injections. The trials included have methodology concerns and none included a placebo control. They included participants with mostly small degenerative tears involving the supraspinatus tendon and the conclusions of this review may not be applicable to traumatic tears, large tears involving the subscapularis tendon or young people. Furthermore, the trials did not assess if surgery could prevent arthritic changes in long-term follow-up. Further well-designed trials in this area that include a placebo-surgery control group and long follow-up are needed to further increase certainty about the effects of surgery for rotator cuff tears.
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Affiliation(s)
- Teemu V Karjalainen
- Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical EpidemiologyMelbourneVICAustralia3144
| | - Nitin B Jain
- Vanderbilt University School of MedicineDepartments of Physical Medicine and Rehabilitation, and Orthopaedics2201 Children's Way, Suite 1318,NashvilleTennesseeUSA37202
| | - Juuso Heikkinen
- University of OuluDivision of Orthopaedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Medical Research CenterOuluFinland
| | - Renea V Johnston
- Monash UniversityMonash Department of Clinical Epidemiology, Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive MedicineMelbourneAustralia
| | - Cristina M Page
- Vanderbilt University School of MedicineDepartments of Physical Medicine and Rehabilitation, and Orthopaedics2201 Children's Way, Suite 1318,NashvilleTennesseeUSA37202
| | - Rachelle Buchbinder
- Monash UniversityMonash Department of Clinical Epidemiology, Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive MedicineMelbourneAustralia
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Barth J, Sirveaux F, Clavert P. Is acromioplasty justifiable? Orthop Traumatol Surg Res 2019; 105:S199-S200. [PMID: 31694802 DOI: 10.1016/j.otsr.2019.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 10/14/2019] [Indexed: 02/02/2023]
Affiliation(s)
- Johannes Barth
- Centre Ostéo-Articulaire des Cèdres, Parc Sud Galaxie, 5, rue des Tropiques, 38130 Echirolles, France
| | | | - Philippe Clavert
- Service de Chirurgie de l'Epaule et du Coude, Hautepierre 2, CHRU Strasbourg, Avenue Molière, 67200 Strasbourg, France.
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Ahmad Z, Parkar A, Shepherd J, Rushton N. Revolving doors of tendinopathy: definition, pathogenesis and treatment. Postgrad Med J 2019; 96:94-101. [PMID: 31757873 DOI: 10.1136/postgradmedj-2019-136786] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 10/01/2019] [Accepted: 10/11/2019] [Indexed: 01/08/2023]
Abstract
The ultimate cure for the tendon pathology continues to elude current science. Despite great steps in technology, the causation and treatment is still not clear. The number of different theories and treatment modalities in the literature may confuse clinicians and patients. In this paper we outline the definitions, evolution of pathogenesis and treatment for tendinopathy. By highlighting these, the aim of this paper is to guide the practitioner in counselling and treating their patients.
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Affiliation(s)
- Zafar Ahmad
- Orthopaedic Research Unit, University of Cambridge, Cambridge, UK
| | - Asif Parkar
- Orthopaedics, Barking Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | | | - Neil Rushton
- Orthopaedic Research Unit, University of Cambridge, Cambridge, UK
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Jain NB, Ayers GD, Fan R, Kuhn JE, Warner JJ, Baumgarten KM, Matzkin E, Higgins LD. Comparative Effectiveness of Operative Versus Nonoperative Treatment for Rotator Cuff Tears: A Propensity Score Analysis From the ROW Cohort. Am J Sports Med 2019; 47:3065-3072. [PMID: 31518155 PMCID: PMC7325686 DOI: 10.1177/0363546519873840] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The evidence to support operative versus nonoperative treatment for rotator cuff tears is sparse and inconclusive. PURPOSE To assess pain and functional outcomes in patients undergoing operative and nonoperative treatments for rotator cuff tears. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS From March 2011 to February 2015, a multicenter cohort of patients with rotator cuff tears undergoing operative and nonoperative treatments was recruited. Patients completed a detailed history questionnaire, the Shoulder Pain and Disability Index (SPADI), and the American Shoulder and Elbow Surgeons (ASES) standardized form and underwent magnetic resonance imaging. In addition to baseline assessments, patients received follow-up questionnaires at 3, 6, 12, and 18 months. Propensity score weighting was used to balance differences in characteristics of the operative and nonoperative groups. RESULTS Adjusted for propensity scores, the operative (n = 50) and nonoperative (n = 77) groups had similar characteristics, as evidenced by the small standardized mean differences between the groups. Adjusted mean differences in the SPADI and ASES scores between the operative and nonoperative groups were -22.0 points (95% CI, -32.1 to -11.8) and -22.2 points (95% CI, -32.8 to -11.6) at 18 months, respectively. The operative group had a significantly higher proportion of patients who showed ≥30% (P = .002) and ≥50% (P < .0001) improvement in SPADI and ASES scores as compared with the nonoperative group. CONCLUSION In this prospective cohort study, patients undergoing operative treatment had significantly better pain and functional outcomes as compared with patients undergoing nonoperative treatment for rotator cuff tears. Differences between the 2 groups in SPADI and ASES scores at the 6- to 18-month time points met the minimal clinically important difference (depending on the threshold used). A large randomized controlled trial is needed to answer this question more definitively.
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Affiliation(s)
- Nitin B. Jain
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
| | - Gregory D. Ayers
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Run Fan
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - John E. Kuhn
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
| | - Jon J.P. Warner
- Department of Orthopaedic Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | - Elizabeth Matzkin
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
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Baldwin M, Snelling S, Dakin S, Carr A. Augmenting endogenous repair of soft tissues with nanofibre scaffolds. J R Soc Interface 2019; 15:rsif.2018.0019. [PMID: 29695606 DOI: 10.1098/rsif.2018.0019] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/04/2018] [Indexed: 12/21/2022] Open
Abstract
As our ability to engineer nanoscale materials has developed we can now influence endogenous cellular processes with increasing precision. Consequently, the use of biomaterials to induce and guide the repair and regeneration of tissues is a rapidly developing area. This review focuses on soft tissue engineering, it will discuss the types of biomaterial scaffolds available before exploring physical, chemical and biological modifications to synthetic scaffolds. We will consider how these properties, in combination, can provide a precise design process, with the potential to meet the requirements of the injured and diseased soft tissue niche. Finally, we frame our discussions within clinical trial design and the regulatory framework, the consideration of which is fundamental to the successful translation of new biomaterials.
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Affiliation(s)
- Mathew Baldwin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah Snelling
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Stephanie Dakin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Jain NB, Ayers GD, Koudelková H, Archer KR, Dickinson R, Richardson B, Derryberry M, Kuhn JE. Operative vs Nonoperative Treatment for Atraumatic Rotator Cuff Tears: A Trial Protocol for the Arthroscopic Rotator Cuff Pragmatic Randomized Clinical Trial. JAMA Netw Open 2019; 2:e199050. [PMID: 31397866 PMCID: PMC6692688 DOI: 10.1001/jamanetworkopen.2019.9050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Rotator cuff disorders remain the most common cause of shoulder pain and are among the most common reasons for patients to seek care in primary and specialty settings. Although operative and nonoperative treatments are offered to patients with atraumatic rotator cuff tears, there is a lack of evidence to support operative vs nonoperative treatment. This paucity of evidence has been highlighted by several professional agencies and experts. OBJECTIVE To perform a pragmatic randomized clinical trial, the Arthroscopic Rotator Cuff trial, comparing pain and functional outcomes in patients undergoing operative vs nonoperative treatment for atraumatic rotator cuff tears, and assessing heterogeneity of treatment effects by age and tear size. DESIGN, SETTING, AND PARTICIPANTS Trial protocol of the Arthroscopic Rotator Cuff trial. This pragmatic randomized clinical trial of an estimated 700 patients is adequately powered to accomplish its aims with 488 patients. Primary analysis will be conducted on an intent-to-treat population in the context of a mixed model. The multicenter trial started recruitment in 2018 with a 1-year follow-up duration. Patients aged 50 years or older to younger than 85 years with magnetic resonance imaging-confirmed atraumatic rotator cuff tears that are suitable for either operative or nonoperative treatment will be enrolled. Block randomization will be performed and stratified by site, age, and tear size. INTERVENTION Nonoperative treatment consists of an approximately 3-month standardized physical therapy program, whereas operative treatment consists of rotator cuff surgery followed by approximately 4 months of postoperative rehabilitation. MAIN OUTCOMES AND MEASURES The primary outcome is patient-reported Shoulder Pain and Disability Index score, and the secondary outcome is American Shoulder and Elbow Surgeons Standardized Shoulder Form score measured at 1 year of follow-up. DISCUSSION The Arthroscopic Rotator Cuff trial is ongoing, and 12 sites with more than 40 physicians are currently recruiting patients. Although there is variation by site, as of May 2, 2019, 13% of all patients screened (787 of 6293) were eligible for the trial, and 9% of eligible patients (74 of 787) were recruited. Results of this study may help patients, clinicians, and policy makers assess the comparative effectiveness of operative vs nonoperative treatment for atraumatic rotator cuff tears. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03295994.
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Affiliation(s)
- Nitin B. Jain
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory D. Ayers
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Helen Koudelková
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kristin R. Archer
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rebecca Dickinson
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian Richardson
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - John E. Kuhn
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
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El-Boghdadly K, Abdallah FW, Short A, Vorobeichik L, Memtsoudis SG, Chan VWS. Outcome Selection and Methodological Quality of Major and Minor Shoulder Surgery Studies: A Scoping Review. Clin Orthop Relat Res 2019; 477:606-619. [PMID: 30624315 PMCID: PMC6382203 DOI: 10.1097/corr.0000000000000578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/31/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Core outcome sets aim to select and standardize the choice of important outcomes reported in clinical trials to encourage more effective data synthesis, increase the reliability of comparing results, and minimize reporting bias. A core outcome set for elective shoulder surgery has yet to be defined, and therefore a systematic assessment of outcomes and methodology is necessary to inform the development of a core outcome set. QUESTIONS/PURPOSES The purpose of this study was to examine randomized controlled trials (RCTs) of patients having elective major or minor shoulder surgery to (1) identify the outcome domains reported; (2) determine specific outcome measurement tools that were utilized; and (3) assess the work for methodological quality and risk of bias. METHODS We conducted a scoping review (a review that identifies the nature and extent of research evidence) to explore the reported outcome domains, outcome tools, and methodological quality from RCTs conducted in shoulder surgery. We considered both major shoulder surgery (defined as arthroplasty, rotator cuff repair, stabilization procedures, biceps tenodesis, or Bankart repairs) and minor shoulder surgery (simple arthroscopy, capsular plication, lateral clavicular excisions, or subacromial decompression). We queried 10 electronic databases for studies published between January 2006 and January 2015. Studies were included if they were prospective, randomized controlled, clinical trials enrolling patients who received an elective shoulder surgical intervention. We extracted data relating to trial characteristics, primary outcomes, tools used to measure these outcomes as well as methodological quality indicators. We assessed indicators of methodological quality by exploring (1) the reproducibility of power analyses; and (2) whether the primary outcomes were powered to minimum clinically important differences. Risk of bias was also assessed with the Jadad score with scores between 0 (very high risk of bias) and 5 (very low risk). Findings were qualitatively analyzed and reported according to systematic and scoping review guidelines. We included 315 studies involving 30,232 patients; 266 studies investigated anesthetic, analgesic, or surgical interventions. RESULTS Of the 315 studies included, the most common outcome domains evaluated were analgesic (n = 104), functional (n = 87), anesthetic (n = 56), and radiologic (n = 29) outcomes, with temporal patterns noted. Studies of major shoulder surgery most commonly reported functional primary outcome domains, whereas minor shoulder surgery studies most frequently reported analgesic primary outcome domains. There were 85 different primary outcome tools utilized, which included 20 functional, 20 anesthetic, 13 analgesic, and 12 radiologic. A methodological quality assessment revealed that 24% of studies had reproducible power analyses, 13% were powered to minimum clinically important differences, and risk of bias assessment demonstrated a median (interquartile range [range]) Jadad score of 4 (3-5 [1-5]). CONCLUSIONS A wide range of outcome domains and outcome assessment tools are in common use in contemporary trials of patients undergoing elective surgery. Although some diversity is important to allow the assessment of patient populations that may have different goals, the large number of tools in common use may impair the ability of future meta-analyses to pool results effectively or even for systematic reviews to synthesize what is known. The limitations of methodological quality in RCTs may be improved by researchers following standard guidelines and considering the minimum clinically important differences in their trials to be of greater use to clinicians and their patients. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Kariem El-Boghdadly
- K. El-Boghdadly, Department of Anaesthesia, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK F. W. Abdallah, Department of Anesthesia and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada; and the Department of Anesthesia and the Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada A. Short, Department of Anaesthesia, Wrightington, Wigan & Leigh NHS Foundation Trust, Wrightington, Lancashire, UK L. Vorobeichik , V. W. S. Chan, Department of Anesthesia, University of Toronto, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada S. G. Memtsoudis, Department of Anesthesiology, Critical Care and Pain Management and Health Care Policy and Research, Weill Cornell Medical College, New York, NY, USA; and the Hospital for Special Surgery, New York, NY, USA
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Karjalainen TV, Jain NB, Page CM, Lähdeoja TA, Johnston RV, Salamh P, Kavaja L, Ardern CL, Agarwal A, Vandvik PO, Buchbinder R. Subacromial decompression surgery for rotator cuff disease. Cochrane Database Syst Rev 2019; 1:CD005619. [PMID: 30707445 PMCID: PMC6357907 DOI: 10.1002/14651858.cd005619.pub3] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgery for rotator cuff disease is usually used after non-operative interventions have failed, although our Cochrane Review, first published in 2007, found that there was uncertain clinical benefit following subacromial decompression surgery. OBJECTIVES To synthesise the available evidence of the benefits and harms of subacromial decompression surgery compared with placebo, no intervention or non-surgical interventions in people with rotator cuff disease (excluding full thickness rotator cuff tears). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and WHO ICRTP registry from 2006 until 22 October 2018, unrestricted by language. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials (RCTs) of adults with rotator cuff disease (excluding full-thickness tears), that compared subacromial decompression surgery with placebo, no treatment, or any other non-surgical interventions. As it is least prone to bias, subacromial decompression compared with placebo was the primary comparison. Other comparisons were subacromial decompression versus exercises or non-operative treatment. Major outcomes were mean pain scores, shoulder function, quality of life, participant global assessment of success, adverse events and serious adverse events. The primary endpoint for this review was one year. For serious adverse events, we also included data from prospective cohort studies designed to record harms that evaluated subacromial decompression surgery or shoulder arthroscopy. DATA COLLECTION AND ANALYSIS We used standard methodologic procedures expected by Cochrane. MAIN RESULTS We included eight trials, with a total of 1062 randomised participants with rotator cuff disease, all with subacromial impingement. Two trials (506 participants) compared arthroscopic subacromial decompression with arthroscopy only (placebo surgery), with all groups receiving postoperative exercises. These trials included a third treatment group: no treatment (active monitoring) in one and exercises in the other. Six trials (556 participants) compared arthroscopic subacromial decompression followed by exercises with exercises alone. Two of these trials included a third arm: sham laser in one and open subacromial decompression in the other.Trial size varied from 42 to 313 participants. Participant mean age ranged between 42 and 65 years. Only two trials reported mean symptom duration (18 to 22 months in one trial and 30 to 31 months in the other), two did not report duration and four reported it categorically.Both placebo-controlled trials were at low risk of bias for the comparison of surgery versus placebo surgery. The other trials were at high risk of bias for several criteria, most notably at risk of performance or detection bias due to lack of participant and personnel blinding. We have restricted the reporting of results of benefits in the Abstract to the placebo-controlled trials.Compared with placebo, high-certainty evidence indicates that subacromial decompression provides no improvement in pain, shoulder function, or health-related quality of life up to one year, and probably no improvement in global success (moderate-certainty evidence, downgraded due to imprecision).At one year, mean pain (on a scale zero to 10, higher scores indicate more pain), was 2.9 points after placebo surgery and 0.26 better (0.84 better to 0.33 worse), after subacromial decompression (284 participants), an absolute difference of 3% (8% better to 3% worse), and relative difference of 4% (12% better to 5% worse). At one year, mean function (on a scale 0 to 100, higher score indicating better outcome), was 69 points after placebo surgery and 2.8 better (1.4 worse to 6.9 better), after surgery (274 participants), an absolute difference of 3% (7% better to 1% worse), and relative difference of 9% (22% better to 4% worse). Global success rate was 97/148 (or 655 per 1000), after placebo and 101/142 (or 708 per 1000) after surgery corresponding to RR 1.08 (95% CI 0.93 to 1.27). Health-related quality of life was 0.73 units (European Quality of Life EQ-5D, -0.59 to 1, higher score indicating better quality of life), after placebo and 0.03 units worse (0.011 units worse to 0.06 units better), after subacromial decompression (285 participants), an absolute difference of 1.3% (5% worse to 2.5% better), and relative difference of 4% (15% worse to 7% better).Adverse events including frozen shoulder or transient minor complications of surgery were reported in approximately 3% of participants across treatment groups in two randomised controlled trials, but due to low event rates we are uncertain if the risks differ between groups: 5/165 (37 per 1000) reported adverse events with subacromial decompression and 9/241 (34 per 1000) with placebo or non-operative treatment, RR 0.91 (95% CI 0.31 to 2.65) (moderate-certainty evidence, downgraded due to imprecision). The trials did not report serious adverse events.Based upon moderate-certainty evidence from two observational trials from the same prospective surgery registry, which also included other shoulder arthroscopic procedures (downgraded for indirectness), the incidence proportion of serious adverse events within 30 days following surgery was 0.5% (0.4% to 0.7%; data collected 2006 to 2011), or 0.6% (0.5 % to 0.7%; data collected 2011 to 2013). Serious adverse events such as deep infection, pulmonary embolism, nerve injury, and death have been observed in participants following shoulder surgery. AUTHORS' CONCLUSIONS The data in this review do not support the use of subacromial decompression in the treatment of rotator cuff disease manifest as painful shoulder impingement. High-certainty evidence shows that subacromial decompression does not provide clinically important benefits over placebo in pain, function or health-related quality of life. Including results from open-label trials (with high risk of bias) did not change the estimates considerably. Due to imprecision, we downgraded the certainty of the evidence to moderate for global assessment of treatment success; there was probably no clinically important benefit in this outcome either compared with placebo, exercises or non-operative treatment.Adverse event rates were low, 3% or less across treatment groups in the trials, which is consistent with adverse event rates reported in the two observational studies. Although precise estimates are unknown, the risk of serious adverse events is likely less than 1%.
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Affiliation(s)
- Teemu V Karjalainen
- Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical EpidemiologyMelbourneVICAustralia3144
- University of HelsinkiFinnish Center of Evidence based Orthopaedics (FICEBO)HelsinkiFinland
| | - Nitin B Jain
- Vanderbilt University School of MedicineDepartments of Physical Medicine and Rehabilitation, and Orthopaedics2201 Children's Way, Suite 1318,NashvilleTennesseeUSA37202
| | - Cristina M Page
- Vanderbilt University School of MedicineDepartments of Physical Medicine and Rehabilitation, and Orthopaedics2201 Children's Way, Suite 1318,NashvilleTennesseeUSA37202
| | - Tuomas A Lähdeoja
- University of HelsinkiFinnish Center of Evidence based Orthopaedics (FICEBO)HelsinkiFinland
- Helsinki University Hospital, Töölö HospitalDepartment of Orthopaedics and TraumatologyHelsinkiFinland
| | - Renea V Johnston
- Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical EpidemiologyMelbourneVICAustralia3144
| | - Paul Salamh
- University of IndianapolisCollege of Health SciencesIndianapolisUSA
| | - Lauri Kavaja
- University of HelsinkiMedical FacultyHelsinkiFinland
- South Carelia Central HospitalDepartment of SurgeryLappeenrantaFinland
| | - Clare L Ardern
- Linköping UniversityDivision of PhysiotherapyLinköpingSweden
- La Trobe UniversitySchool of Allied HealthMelbourneAustralia
| | - Arnav Agarwal
- University of TorontoDepartment of MedicineTorontoCanada
| | - Per O Vandvik
- Lovisenberg Diaconal HospitalDepartment of MedicineOsloNorway
- University of OsloFaculty of Medicine, Institute of Health and SocietyOsloNorway
| | - Rachelle Buchbinder
- Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical EpidemiologyMelbourneVICAustralia3144
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Khan M, Alolabi B, Horner N, Bedi A, Ayeni OR, Bhandari M. Surgery for shoulder impingement: a systematic review and meta-analysis of controlled clinical trials. CMAJ Open 2019; 7:E149-E158. [PMID: 30846616 PMCID: PMC6411477 DOI: 10.9778/cmajo.20180179] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Shoulder impingement is one of the most common nontraumatic upper limb causes of disability in adults. Our aim was to evaluate the efficacy of surgical intervention in comparison with nonoperative or sham treatments in patients with shoulder impingement in terms of both pain and functional outcomes. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials. Two reviewers independently screened MEDLINE, Embase, PubMed and Cochrane databases for randomized controlled trials published from 1946 to July 19, 2018. A risk-of-bias assessment was conducted for all included studies, and outcomes were pooled using a random effects model. The primary outcome was improvement in pain up to 2 years. Secondary outcomes were functional outcome scores reported in the short term (≤ 1 yr) and long term (≥ 2 yr). Heterogeneity was assessed using the I 2 statistic. Functional outcome scores were presented along with minimal clinically important differences to provide clinical context for findings. RESULTS Thirteen randomized controlled trials (n = 1062 patients) were included in this review. Eligible patients had a mean age of 48 (standard deviation ± 4) years and 45% were men. The pooled treatment effect of surgical intervention for shoulder impingement did not demonstrate any benefit to surgery with respect to pain relief (mean difference -0.07, 95% CI -0.40 to 0.26) or short-term functional outcomes (standardized mean difference -0.09, 95% confidence interval [CI] -0.27 to 0.08). Surgical intervention did result in a small statistically significant but clinically unimportant improvement in long-term functional outcomes (standardized mean difference 0.23, 95% CI 0.06 to 0.41). INTERPRETATION Evidence suggests surgical intervention has little, if any, benefit for impingement pathology in the middle-aged patient. Further research is required to identify those patients who will reliably benefit from surgical intervention as well as optimal conservative treatment strategies.
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Affiliation(s)
- Moin Khan
- Division of Orthopaedic Surgery, Department of Surgery (Khan, Alolabi, Horner, Ayeni, Bhandari), McMaster University, Hamilton, Ont.; MedSport (Bedi), University of Michigan, Ann Arbor, Mich.; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont.
| | - Bashar Alolabi
- Division of Orthopaedic Surgery, Department of Surgery (Khan, Alolabi, Horner, Ayeni, Bhandari), McMaster University, Hamilton, Ont.; MedSport (Bedi), University of Michigan, Ann Arbor, Mich.; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont
| | - Nolan Horner
- Division of Orthopaedic Surgery, Department of Surgery (Khan, Alolabi, Horner, Ayeni, Bhandari), McMaster University, Hamilton, Ont.; MedSport (Bedi), University of Michigan, Ann Arbor, Mich.; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont
| | - Asheesh Bedi
- Division of Orthopaedic Surgery, Department of Surgery (Khan, Alolabi, Horner, Ayeni, Bhandari), McMaster University, Hamilton, Ont.; MedSport (Bedi), University of Michigan, Ann Arbor, Mich.; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery (Khan, Alolabi, Horner, Ayeni, Bhandari), McMaster University, Hamilton, Ont.; MedSport (Bedi), University of Michigan, Ann Arbor, Mich.; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery (Khan, Alolabi, Horner, Ayeni, Bhandari), McMaster University, Hamilton, Ont.; MedSport (Bedi), University of Michigan, Ann Arbor, Mich.; Department of Clinical Epidemiology and Biostatistics (Bhandari), McMaster University, Hamilton, Ont
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Cook JA, Merritt N, Rees JL, Crocker JC, Hopewell S, Dritsaki M, Beard DJ, Rangan A, Cooper C, Kottam L, Farrar-Hockley D, Thomas M, Earle R, Carr AJ. Patch-augmented rotator cuff surgery (PARCS) study-protocol for a feasibility study. Pilot Feasibility Stud 2018; 4:188. [PMID: 30598834 PMCID: PMC6302398 DOI: 10.1186/s40814-018-0380-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 12/06/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND A rotator cuff tear is a common disabling shoulder problem. Symptoms include pain, weakness, lack of shoulder mobility and sleep disturbance. Many patients require surgery to repair the tear; however, there is a high failure rate. There is a pressing need to improve the outcome of rotator cuff surgery and the use of patch augmentation to provide support to the healing process and improve patient outcomes holds new promise. Patches have been made using different materials (e.g. human/animal skin or intestine tissue, and completely synthetic materials) and processes (e.g. woven or a mesh). However, clinical evidence on their use is limited. The aim of the patch-augmented rotator cuff surgery (PARCS) feasibility study is to determine, using a mixed method approach, the design of a definitive randomised trial assessing the effectiveness and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and feasible. METHODS The objectives of this six-stage mixed methods feasibility study are to determine current practice, evidence and views about patch use; achieve consensus on the design of a randomised trial to evaluate patch-augmented rotator cuff surgery; and assess the acceptability and feasibility of the proposed design. The six stages will involve a systematic review of clinical evidence, two surveys of surgeons, focus groups and interviews with stakeholders, a Delphi study and a consensus meeting. The various stakeholders (including patients, surgeons, and representatives from industry, the NHS and regulatory bodies) will be involved across the six stages. DISCUSSION The PARCS feasibility study will inform the feasibility and acceptability of a randomised trial of the effectiveness and cost-effectiveness of a patch-augmented rotator cuff surgery. Consensus opinion on the basic design of a randomised trial will be sought. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Jonathan A Cook
- 1Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- 2NIHR Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Naomi Merritt
- 2NIHR Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jonathan L Rees
- 2NIHR Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joanna C Crocker
- 3Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- 4NIHR Oxford Biomedical Research Centre, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- 1Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- 1Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David J Beard
- 2NIHR Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amar Rangan
- 2NIHR Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- 5The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Cushla Cooper
- 2NIHR Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lucksy Kottam
- 5The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Dair Farrar-Hockley
- 2NIHR Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Michael Thomas
- 6Frimley Park Hospital, Frimley Park Hospital NHS Foundation Trust, Surrey, UK
| | - Robert Earle
- 2NIHR Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew J Carr
- 2NIHR Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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CORR Insights®: Does Distal Clavicle Resection Decrease Pain or Improve Shoulder Function in Patients With Acromioclavicular Joint Arthritis and Rotator Cuff Tears? A Meta-analysis. Clin Orthop Relat Res 2018; 476:2415-2417. [PMID: 30179961 PMCID: PMC6259888 DOI: 10.1097/corr.0000000000000441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Greenall G, Carr A, Beard D, Rees J, Rangan A, Merritt N, Dritsaki M, Nagra NS, Baldwin M, Hopewell S, Cook JA. Systematic review of the surgical management of rotator cuff repair with an augmentative patch: a feasibility study protocol. Syst Rev 2018; 7:187. [PMID: 30424809 PMCID: PMC6234662 DOI: 10.1186/s13643-018-0851-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 10/22/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Shoulder pain is a common problem in the general population and is responsible for prolonged periods of disability, loss of productivity, absence from work and inability to carry out household activities. Rotator cuff problems account for up to 70% of shoulder pain problems and are the third most prevalent musculoskeletal disorder after those occurring in the lower back and neck. Rotator cuff surgery has high failure rates (25-50% within 12 months), and as a result, there is a pressing need to improve the outcome of rotator cuff surgery. Patch augmented surgery for rotator cuff repairs has recently been developed and is increasingly being used within the UK National Health Service. Patch augmented surgery could lead to a dramatic improvement in patient and surgical outcomes, but its clinical and cost effectiveness needs rigorous evaluation. The existing evidence on the use of patches may be at risk of bias as currently only a small number of single-centre comparative studies appear to have been carried out. Additionally, it is unclear for which patches a clinical study (comparative and non-comparative) has been conducted. This paper outlines the protocol for a systematic review intended to summarise the best available clinical evidence and will indicate what further research is required. METHODS Electronic databases (Medline, Embase and Cochrane) will be systematically searched between April 2006 and the present day for relevant publications using a specified search strategy, which can be adapted for the use in multiple electronic databases, and inclusion criteria. Screening of both titles and abstracts will be done by two independent reviewers with any discrepancies resolved by a third independent reviewer. Data extraction will include information regarding the type of participants, type of intervention and outcomes including but not limited to shoulder-specific function and pain scores, patch-related adverse events and type of study. The results will be summarised in a narrative review where qualitative analysis is not possible. DISCUSSION This review aims to collate the current evidence base regarding the use of patches to augment rotator cuff repair. The results of this review will help to develop, using consensus methods, the design of a definitive randomised trial assessing the clinical and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and is feasible. SYSTEMATIC REVIEW REGISTRATION CRD42017057908.
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Affiliation(s)
- Gemma Greenall
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jonathan Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Naomi Merritt
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Navraj S. Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mathew Baldwin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jonathan A. Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Monesi R, Benedetti MG, Zati A, Vigna D, Romanello D, Monello A, Rotini R. The Effects of a Standard Postoperative Rehabilitation Protocol for Arthroscopic Rotator Cuff Repair on Pain, Function, and Health Perception. JOINTS 2018; 6:145-152. [PMID: 30582101 PMCID: PMC6301846 DOI: 10.1055/s-0038-1673701] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 08/27/2018] [Indexed: 01/20/2023]
Abstract
Purpose
There is still conflicting evidence to support postoperative rehabilitation protocols using immobilization following rotator cuff repair over early motion. The objective of the study was to evaluate the evolution of pain, shoulder function, and patients' perception of their health status up to 1 year after cuff rotator repair and a standard postoperative rehabilitation protocol consisting of 4 weeks of immobilization followed by a 2-week assisted controlled rehabilitation.
Methods
Descriptive, longitudinal, uncontrolled case-series study was performed on 49 patients who underwent arthroscopic rotator cuff repair following traumatic or degenerative lesions. VAS scale for pain, Constant–Murley score for function, and SF-12 score for quality of life were used as outcome measures and were administered before the rehabilitation treatment, at the end of the 2-week rehabilitation, 3 months, and 1 year after surgery.
Results
VAS pain score decreased significantly along the follow-up reaching almost a nil value after 1 year (0.2). Function as measured by Constant–Murley score had a significant improvement during follow-up, reaching a mean value of 84.6. The short form (SF)-12 score increased over time reaching 46.3 for the physical and 43.8 for the psychological dimension, respectively, at 1 year.
Conclusion
The present study confirmed an excellent outcome at 1 year after rotator cuff repair using a traditional 4-week immobilization followed by a 2-week rehabilitation protocol without evidence of tendon un-healing or re-tearing.
Level of Evidence
This is a level IV, therapeutic case series.
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Affiliation(s)
- Roberta Monesi
- Physical Medicine and Rehabilitation Unit, IRCCS-Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Maria Grazia Benedetti
- Physical Medicine and Rehabilitation Unit, IRCCS-Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Zati
- Physical Medicine and Rehabilitation Unit, IRCCS-Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Daniela Vigna
- Physical Medicine and Rehabilitation Unit, IRCCS-Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Domenico Romanello
- Physical Medicine and Rehabilitation Unit, IRCCS-Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alberto Monello
- Physical Medicine and Rehabilitation Unit, IRCCS-Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Roberto Rotini
- Division of Shoulder and Elbow Orthopedic, IRCCS-Istituto Ortopedico Rizzoli, Bologna, Italy
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Kjær BH, Magnusson SP, Warming S, Henriksen M, Krogsgaard MR, Juul-Kristensen B. Progressive early passive and active exercise therapy after surgical rotator cuff repair - study protocol for a randomized controlled trial (the CUT-N-MOVE trial). Trials 2018; 19:470. [PMID: 30176943 PMCID: PMC6122575 DOI: 10.1186/s13063-018-2839-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 08/04/2018] [Indexed: 01/08/2023] Open
Abstract
Background Rotator cuff tear is a common cause of shoulder disability and results in patients predominantly complaining of pain and loss of motion and strength. Traumatic rotator cuff tears are typically managed surgically followed by ~ 20 weeks of rehabilitation. However, the timing and intensity of the postoperative rehabilitation strategy required to reach an optimal clinical outcome is unknown. Early controlled and gradually increased tendon loading has been suggested to positively influence tendon healing and recovery. The aim of this trial is therefore to examine the effect of a progressive rehabilitation strategy on pain, physical function and quality of life compared to usual care (that limits tendon loading in the early postoperative phase) in patients who have a rotator cuff repair of a traumatic tear. Methods The current study is a randomized, controlled, outcome-assessor blinded, multicenter, superiority trial with a two-group paralleled design. A total of 100 patients with surgically repaired traumatic rotator cuff tears will be recruited from up to three orthopedic departments in Denmark, and randomized to either a progressive early passive and active movement program or a limited early passive movement program (usual care). The primary outcome measure will be the change from pre-surgery to 12 weeks post-surgery in the Western Ontario Rotator Cuff Index questionnaire. Secondary outcomes include the Disabilities Arm, Shoulder and Hand questionnaire (DASH), range of motion, strength and tendon healing characteristics from ultrasound measurements at 12 months follow up. Discussion We hypothesized that patients who receive the progressive rehabilitation strategy will benefit more with respect to pain reduction, physical function and quality of life than those who receive care as usual. If this is confirmed our study can be used clinically to enhance the recovery of patients with traumatic rotator cuff tear. Trial registration ClinicalTrials.gov, NCT02969135. Registered on 15 November 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2839-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Birgitte Hougs Kjær
- Department of Physical and Occupational Therapy, Bispebjerg-Frederiksberg Hospital, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark. .,Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, DK-5230, Odense, Denmark.
| | - S Peter Magnusson
- Department of Physical and Occupational Therapy, Bispebjerg-Frederiksberg Hospital, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark.,Institute of Sports Medicine, Department of Orthopaedic Surgery M, Copenhagen Bispebjerg-Frederiksberg Hospital, and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Susan Warming
- Department of Physical and Occupational Therapy, Bispebjerg-Frederiksberg Hospital, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark
| | - Marius Henriksen
- Department of Physical and Occupational Therapy, Bispebjerg-Frederiksberg Hospital, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark.,The Parker Institute, Bispebjerg-Frederiksberg Hospital, Ndr. Fasanvej 57, DK-2000, Frederiksberg, Copenhagen, Denmark
| | - Michael Rindom Krogsgaard
- Section for Sports Traumatology M51, Department of Orthopaedic Surgery, Bispebjerg-Frederiksberg Hospital, Bispebjerg Bakke 23, DK-2400, Copenhagen, Denmark
| | - Birgit Juul-Kristensen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, DK-5230, Odense, Denmark
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Jancuska J, Matthews J, Miller T, Kluczynski MA, Bisson LJ. A Systematic Summary of Systematic Reviews on the Topic of the Rotator Cuff. Orthop J Sports Med 2018; 6:2325967118797891. [PMID: 30320144 PMCID: PMC6154263 DOI: 10.1177/2325967118797891] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The number of systematic reviews and meta-analyses published on the rotator cuff (RC) has increased markedly. PURPOSE To quantify the number of systematic reviews and meta-analyses published on the RC and to provide a qualitative summary of the literature. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic search for all systematic reviews and meta-analyses pertaining to the RC published between January 2007 and September 2017 was performed with PubMed, MEDLINE, and the Cochrane Database of Systematic Reviews. Narrative reviews and non-English language articles were excluded. RESULTS A total of 1078 articles were found, of which 196 met the inclusion criteria. Included articles were summarized and divided into 15 topics: anatomy and function, histology and genetics, diagnosis, epidemiology, athletes, nonoperative versus operative treatment, surgical repair methods, concomitant conditions and surgical procedures, RC tears after total shoulder arthroplasty, biological augmentation, postoperative rehabilitation, outcomes and complications, patient-reported outcome measures, cost-effectiveness of RC repair, and quality of randomized controlled trials. CONCLUSION A qualitative summary of the systematic reviews and meta-analyses published on the RC can provide surgeons with a single source of the most current literature.
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Affiliation(s)
- Jeffrey Jancuska
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical
Science, University at Buffalo, Buffalo, New York, USA
| | - John Matthews
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical
Science, University at Buffalo, Buffalo, New York, USA
| | - Tyler Miller
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical
Science, University at Buffalo, Buffalo, New York, USA
| | - Melissa A. Kluczynski
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical
Science, University at Buffalo, Buffalo, New York, USA
| | - Leslie J. Bisson
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical
Science, University at Buffalo, Buffalo, New York, USA
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Witten A, Clausen MB, Thorborg K, Attrup ML, Hölmich P. Patients who are candidates for subacromial decompression have more pronounced range of motion deficits, but do not differ in self-reported shoulder function, strength or pain compared to non-candidates. Knee Surg Sports Traumatol Arthrosc 2018; 26:2505-2511. [PMID: 29550858 DOI: 10.1007/s00167-018-4894-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 03/08/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Subacromial impingement syndrome (SIS) is associated with low self-reported shoulder function, impairments in shoulder strength and range of motion (ROM), and pain. It is not known how the symptomatology associated with SIS is reflected in the choice of treatment. This study compares self-reported shoulder function, shoulder strength, ROM, and pain in patients with SIS considered candidates and non-candidates for subacromial decompression (SAD). METHOD Self-reported shoulder function (Q-DASH and SPADI), maximum isometric muscle strength in shoulder abduction (Abd-strength) and external rotation (ER-strength), active abduction ROM (Abd-ROM) and passive internal rotation ROM (IR-ROM) were measured in a consecutive cohort of patients with SIS referred to an orthopedic outpatient clinic. Additionally, pain during each test and pain levels during the last week were reported. Patients were categorized as candidates or non-candidates for SAD based on their consultation with an orthopedic specialist blinded to test results and self-reported shoulder function. All outcomes and age, gender, weight and duration of symptoms were compared using the unpaired t test or Mann-Whitney's U test as appropriate. RESULTS One-hundred and fifty-seven patients were included. 25 patients were candidates for SAD, while 132 were not. SAD candidates had significantly lower Abd-ROM (87° vs. 112°, p = 0.011, effect size = 0. 15) and IR-ROM (114° vs. 123°, p = 0.026, effect size = 0.58) additional to higher pain during test of Abd-strength (5.3 vs. 3.7, p = 0.02, effect size = 0.21). No other differences were found between the groups. CONCLUSION A decrease in abduction and internal rotation range of motion, and increased pain during maximal abduction strength effort are associated with being considered a candidate for subacromial decompression, while self-reported shoulder function, pain during the last week, and rotator cuff strength are not. As SAD candidates primarily differentiates from non-candidates by having more pronounced ROM deficits, it might be important to address ROM in pre- and postsurgical evaluations, but as the overall differences between the two groups seem minor, the relation between impairments and the choice of treatment needs further clarification. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Adam Witten
- Sports Orthopedic Research Center - Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager & Hvidovre, Denmark.
| | - Mikkel B Clausen
- Sports Orthopedic Research Center - Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager & Hvidovre, Denmark.,Department of Physiotherapy and Occupational Therapy, University College Copenhagen, Copenhagen, Denmark
| | - Kristian Thorborg
- Sports Orthopedic Research Center - Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager & Hvidovre, Denmark
| | - Mikkel L Attrup
- Sports Orthopedic Research Center - Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager & Hvidovre, Denmark
| | - Per Hölmich
- Sports Orthopedic Research Center - Copenhagen, Department of Orthopedic Surgery, Copenhagen University Hospital, Amager & Hvidovre, Denmark
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Minkalis AL, Vining RD, Long CR, Hawk C, de Luca K. A systematic review of thrust manipulation combined with one conservative intervention for rotator cuff and related non-surgical shoulder conditions. THE JOURNAL OF THE CANADIAN CHIROPRACTIC ASSOCIATION 2018; 62:5-17. [PMID: 30270924 PMCID: PMC6160900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To determine effects of thrust manipulation plus one conservative intervention for non-surgical shoulder pain and disability due to rotator cuff dysfunction. METHODS This review followed PRISMA guidelines. The databases searched were PubMed, PEDro, ICL, CINAHL, and AMED. Included were randomized trials with at least one group assigned to receive thrust manipulation and one adjunct conservative therapy. The PEDro scale was used to assess methodological quality and GRADE for analysis. RESULTS The search yielded 2088 articles with one meeting eligibility criteria. The trial examined thrust manipulation with exercise compared to sham. Statistically significant improvements in pain and disability were reported within but not between groups. Evidence quality according to the PEDro scale was good; GRADE was moderate. CONCLUSION Few trials have been conducted studying thrust manipulation plus another conservative intervention for rotator cuff conditions rendering available evidence of thrust manipulation plus exercise insufficient to determine effects of this combined treatment.
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Chester R, Jerosch-Herold C, Lewis J, Shepstone L. Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study. Br J Sports Med 2018; 52:269-275. [PMID: 27445360 PMCID: PMC5867439 DOI: 10.1136/bjsports-2016-096084] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2016] [Indexed: 11/13/2022]
Abstract
BACKGROUND/AIM Shoulder pain is a major musculoskeletal problem. We aimed to identify which baseline patient and clinical characteristics are associated with a better outcome, 6 weeks and 6 months after starting a course of physiotherapy for shoulder pain. METHODS 1030 patients aged ≥18 years referred to physiotherapy for the management of musculoskeletal shoulder pain were recruited and provided baseline data. 840 (82%) provided outcome data at 6 weeks and 811 (79%) at 6 months. 71 putative prognostic factors were collected at baseline. Outcomes were the Shoulder Pain and Disability Index (SPADI) and Quick Disability of the Arm, Shoulder and Hand Questionnaire. Multivariable linear regression was used to analyse prognostic factors associated with outcome. RESULTS Parameter estimates (β) are presented for the untransformed SPADI at 6 months, a negative value indicating less pain and disability. 4 factors were associated with better outcomes for both measures and time points: lower baseline disability (β=-0.32, 95% CI -0.23 to -0.40), patient expectation of 'complete recovery' compared to 'slight improvement' as 'a result of physiotherapy' (β=-12.43, 95% CI -8.20 to -16.67), higher pain self-efficacy (β=-0.36, 95% CI -0.50 to -0.22) and lower pain severity at rest (β=-1.89, 95% CI -1.26 to -2.51). CONCLUSIONS Psychological factors were consistently associated with patient-rated outcome, whereas clinical examination findings associated with a specific structural diagnosis were not. When assessing people with musculoskeletal shoulder pain and considering referral to physiotherapy services, psychosocial and medical information should be considered. STUDY REGISTRATION Protocol published at http://www.biomedcentral.com/1471-2474/14/192.
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Affiliation(s)
- Rachel Chester
- Faculty of Medicine and Health Sciences, School of Health Sciences, University of East Anglia, Norwich, Norfolk, UK
- Physiotherapy Department, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
| | - Christina Jerosch-Herold
- Faculty of Medicine and Health Sciences, School of Health Sciences, University of East Anglia, Norwich, Norfolk, UK
| | - Jeremy Lewis
- Department of Allied Health Professions, School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Lee Shepstone
- Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
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Beard DJ, Rees JL, Cook JA, Rombach I, Cooper C, Merritt N, Shirkey BA, Donovan JL, Gwilym S, Savulescu J, Moser J, Gray A, Jepson M, Tracey I, Judge A, Wartolowska K, Carr AJ. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet 2018; 391:329-338. [PMID: 29169668 PMCID: PMC5803129 DOI: 10.1016/s0140-6736(17)32457-1] [Citation(s) in RCA: 263] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 06/20/2017] [Accepted: 08/29/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Arthroscopic sub-acromial decompression (decompressing the sub-acromial space by removing bone spurs and soft tissue arthroscopically) is a common surgery for subacromial shoulder pain, but its effectiveness is uncertain. We did a study to assess its effectiveness and to investigate the mechanism for surgical decompression. METHODS We did a multicentre, randomised, pragmatic, parallel group, placebo-controlled, three-group trial at 32 hospitals in the UK with 51 surgeons. Participants were patients who had subacromial pain for at least 3 months with intact rotator cuff tendons, were eligible for arthroscopic surgery, and had previously completed a non-operative management programme that included exercise therapy and at least one steroid injection. Exclusion criteria included a full-thickness torn rotator cuff. We randomly assigned participants (1:1:1) to arthroscopic subacromial decompression, investigational arthroscopy only, or no treatment (attendance of one reassessment appointment with a specialist shoulder clinician 3 months after study entry, but no intervention). Arthroscopy only was a placebo as the essential surgical element (bone and soft tissue removal) was omitted. We did the randomisation with a computer-generated minimisation system. In the surgical intervention groups, patients were not told which type of surgery they were receiving (to ensure masking). Patients were followed up at 6 months and 1 year after randomisation; surgeons coordinated their waiting lists to schedule surgeries as close as possible to randomisation. The primary outcome was the Oxford Shoulder Score (0 [worst] to 48 [best]) at 6 months, analysed by intention to treat. The sample size calculation was based upon a target difference of 4·5 points (SD 9·0). This trial has been registered at ClinicalTrials.gov, number NCT01623011. FINDINGS Between Sept 14, 2012, and June 16, 2015, we randomly assigned 313 patients to treatment groups (106 to decompression surgery, 103 to arthroscopy only, and 104 to no treatment). 24 [23%], 43 [42%], and 12 [12%] of the decompression, arthroscopy only, and no treatment groups, respectively, did not receive their assigned treatment by 6 months. At 6 months, data for the Oxford Shoulder Score were available for 90 patients assigned to decompression, 94 to arthroscopy, and 90 to no treatment. Mean Oxford Shoulder Score did not differ between the two surgical groups at 6 months (decompression mean 32·7 points [SD 11·6] vs arthroscopy mean 34·2 points [9·2]; mean difference -1·3 points (95% CI -3·9 to 1·3, p=0·3141). Both surgical groups showed a small benefit over no treatment (mean 29·4 points [SD 11·9], mean difference vs decompression 2·8 points [95% CI 0·5-5·2], p=0·0186; mean difference vs arthroscopy 4·2 [1·8-6·6], p=0·0014) but these differences were not clinically important. There were six study-related complications that were all frozen shoulders (in two patients in each group). INTERPRETATION Surgical groups had better outcomes for shoulder pain and function compared with no treatment but this difference was not clinically important. Additionally, surgical decompression appeared to offer no extra benefit over arthroscopy only. The difference between the surgical groups and no treatment might be the result of, for instance, a placebo effect or postoperative physiotherapy. The findings question the value of this operation for these indications, and this should be communicated to patients during the shared treatment decision-making process. FUNDING Arthritis Research UK, the National Institute for Health Research Biomedical Research Centre, and the Royal College of Surgeons (England).
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK.
| | - Jonathan L Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | - Ines Rombach
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | - Naomi Merritt
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | - Beverly A Shirkey
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK
| | - Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol
| | - Stephen Gwilym
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK
| | - Julian Savulescu
- Institute for Science and Ethics, University of Oxford, Littlegate House, Oxford, UK
| | - Jane Moser
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK
| | - Alastair Gray
- Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Headington, Oxford, UK
| | - Marcus Jepson
- School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol
| | - Irene Tracey
- Nuffield Department of Clinical Neurosciences, University of Oxford, Headington, Oxford, UK
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK
| | - Karolina Wartolowska
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK.
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Kvalvaag E, Anvar M, Karlberg AC, Brox JI, Engebretsen KB, Soberg HL, Juel NG, Bautz-Holter E, Sandvik L, Roe C. Shoulder MRI features with clinical correlations in subacromial pain syndrome: a cross-sectional and prognostic study. BMC Musculoskelet Disord 2017; 18:469. [PMID: 29157224 PMCID: PMC5696760 DOI: 10.1186/s12891-017-1827-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 11/10/2017] [Indexed: 12/11/2022] Open
Abstract
Background Previous studies on shoulder patients have suggested that the prevalence of rotator cuff or bursa abnormalities are weakly related to symptoms and that similar findings are often found in asymptomatic persons. In addition, it is largely unknown whether structural changes identified by magnetic resonance imaging (MRI) affect outcome after treatment for shoulder pain. The purpose of this study was therefore to evaluate the presence of structural changes on MRI in patients with subacromial pain syndrome and to determine to what extent these changes are associated with symptoms and predict outcome after treatment (evaluated by the Shoulder Pain and Disability Index (SPADI)). Methods A prospective, observational assessment of a subset of shoulder patients who were included in a randomized study was performed. All participants had an MRI of the shoulder. An MRI total score for findings at the AC joint, subacromial bursa and rotator cuff was calculated. Multiple linear regression analysis was applied to examine the relationship between the MRI total score and the outcome measure at baseline and to examine to what extent the MRI total score was associated with the change in the SPADI score from baseline to the one year follow-up. Results There was a weak, inverse association between the SPADI score at baseline and the MRI total score (β = −3.1, with 95% CI −5.9 to −0.34; p = 0.03), i.e. the SPADI score was higher for patients with a lower MRI total score. There was an association between the change in the SPADI score from baseline to the one year follow-up and the MRI total score (β = 8.1, 95% CI -12.3 to −3.8; p < 0.001), with a poorer outcome for patients with a higher MRI total score. Both tendinosis (p = 0.01) and bursitis (p = 0.04) were associated with a poorer outcome after one year. Conclusions In this study, MRI findings were significantly associated with the change in the SPADI score from baseline and to one year follow-up, with a poorer outcome after treatment for the patients with higher MRI total score, tendinosis and bursitis on MRI. Trial registration Clinicaltrials.gov no NCT01441830. September 28, 2011.
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Affiliation(s)
- Elisabeth Kvalvaag
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, Ullevaal, Postboks 4956 Nydalen, 0424, Oslo, Norway. .,University of Oslo, Medical Faculty, Boks 1072 Blindern, 0316, Oslo, Norway.
| | - Masoud Anvar
- Department of Radiology, Oslo University Hospital HF, Ullevaal, Postboks 4956 Nydalen, 0424, Oslo, Norway
| | - Anna Cecilia Karlberg
- Department of Radiology, Oslo University Hospital HF, Ullevaal, Postboks 4956 Nydalen, 0424, Oslo, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, Ullevaal, Postboks 4956 Nydalen, 0424, Oslo, Norway
| | - Kaia Beck Engebretsen
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, Ullevaal, Postboks 4956 Nydalen, 0424, Oslo, Norway
| | - Helene Lundgaard Soberg
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, Ullevaal, Postboks 4956 Nydalen, 0424, Oslo, Norway
| | - Niels Gunnar Juel
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, Ullevaal, Postboks 4956 Nydalen, 0424, Oslo, Norway
| | - Erik Bautz-Holter
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, Ullevaal, Postboks 4956 Nydalen, 0424, Oslo, Norway
| | - Leiv Sandvik
- University of Oslo, Faculty of Dentistry, Boks 1072 Blindern, 0316, Oslo, Norway
| | - Cecilie Roe
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital HF, Ullevaal, Postboks 4956 Nydalen, 0424, Oslo, Norway.,University of Oslo, Medical Faculty, Boks 1072 Blindern, 0316, Oslo, Norway
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40
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Björnsson Hallgren HC, Adolfsson LE, Johansson K, Öberg B, Peterson A, Holmgren TM. Specific exercises for subacromial pain. Acta Orthop 2017; 88:600-605. [PMID: 28812398 PMCID: PMC5694803 DOI: 10.1080/17453674.2017.1364069] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - We have previously shown that specific exercises reduced the need for surgery in subacromial pain patients at 1-year follow-up. We have now investigated whether this result was maintained after 5 years and compared the outcomes of surgery and non-surgical treatment. Patients and methods - 97 patients were included in the previously reported randomized study of patients on a waiting list for surgery. These patients were randomized to specific or unspecific exercises. After 3 months of exercises the patients were asked if they still wanted surgery and this was also assessed at the present 5-year follow-up. The 1-year assessment included Constant-Murley score, DASH, VAS at night, rest and activity, EQ-5D, and EQ-VAS. All these outcome assessments were repeated after 5 years in 91 of the patients. Results - At the 5-year follow-up more patients in the specific exercise group had declined surgery, 33 of 47 as compared with 16 of 44 (p = 0.001) in the unspecific exercise group. The mean Constant-Murley score continued to improve between the 1- and 5-year follow-ups in both surgically and non-surgically treated groups. On a group level there was no clinically relevant change between 1 and 5 years in any of the other outcome measures regardless of treatment. Interpretation - This 5-year follow-up of a previously published randomized controlled trial found that specific exercises reduced the need for surgery in patients with subacromial pain. Patients not responding to specific exercises may achieve similar good results with surgery. These findings emphasize that a specific exercise program may serve as a selection tool for surgery.
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Affiliation(s)
- Hanna C Björnsson Hallgren
- Institution for Clinical and Experimental Medicine, Division of Orthopaedics, Linköping University,Correspondence:
| | - Lars E Adolfsson
- Institution for Clinical and Experimental Medicine, Division of Orthopaedics, Linköping University
| | - Kajsa Johansson
- Institution of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Sweden
| | - Birgitta Öberg
- Institution of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Sweden
| | - Anna Peterson
- Institution for Clinical and Experimental Medicine, Division of Orthopaedics, Linköping University
| | - Theresa M Holmgren
- Institution for Clinical and Experimental Medicine, Division of Orthopaedics, Linköping University
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Palenius KG, Nyman PC. Expectations and experiences of physiotherapeutic practice among patients with shoulder problems. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2017. [DOI: 10.1080/21679169.2017.1363283] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Kaj Göran Palenius
- Faculty of Education and Welfare Studies, Åbo Akademi University, Jakobstad, Finland
| | - Pia Carola Nyman
- Department of Social Services and Health Care, City of Jakobstad, Jakobstad, Finland
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Joo H, Lee YJ, Shin JS, Lee J, Kim MR, Koh W, Park Y, Song YK, Cho JH, Ha IH. Medical service use and usual care of common shoulder disorders in Korea: a cross-sectional study using the Health Insurance Review and Assessment Service National Patient Sample. BMJ Open 2017; 7:e015848. [PMID: 28706100 PMCID: PMC5726070 DOI: 10.1136/bmjopen-2017-015848] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 06/03/2017] [Accepted: 06/09/2017] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES This study examined National Health Insurance claims data to investigate the epidemiology of shoulder disorders in Korea. Detailed information on medical services and related costs was assessed by major shoulder disorder category. DESIGN AND SETTING The 2014 National Patient Sample dataset provided by the Health Insurance Review and Assessment Service was analysed. Among shoulder-related diagnosis codes, adhesive capsulitis of the shoulder (ACS), rotator cuff syndrome (RCS) and shoulder impingement syndrome (SIS) categories were of highest prevalence. Sociodemographic characteristics and medical service use, frequency and medical costs regarding common shoulder disorders were evaluated. RESULTS The majority of patients with shoulder disorder received ambulatory care (97%). Total and per-patient expenses were highest in patients with RCS. The number of inpatients with RCS was more than twice that of the other two groups, and patients with RCS were more likely to receive surgical management compared with patients with ACS and SIS. Prevalence of shoulder disorders was highest among subjects in their 50s for all three groups. Primary care physicians treated 75.80% of patients with ACS, 56.99% of patients with RCS and 48.06% of patients with SIS, respectively, outlining the difference in medical institution usage patterns. In all three groups, the highest proportion of patients visited orthopaedic surgeons out of medical departments. In the ACS and SIS groups, cost of visits (consultations) took up the largest part of total expenses at 32.30% and 18.88%, respectively, while cost of procedure/surgery constituted the largest portion in patients with RCS (37.77%). The usage proportion of subcutaneous or intramuscular and intra-articular injections ranged between 20% and 30% for outpatients in all three groups. CONCLUSIONS Medical service use, frequency and cost distributions relating to major shoulder disorders in Korea were assessed using nationwide claims data. These findings are expected to aid policy-makers as well as researchers and practitioners as basic healthcare data.
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Affiliation(s)
- Hwansoo Joo
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, The Republic of Korea
| | - Yoon Jae Lee
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, The Republic of Korea
| | - Joon-Shik Shin
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, The Republic of Korea
| | - Jinho Lee
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, The Republic of Korea
| | - Me-riong Kim
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, The Republic of Korea
| | - Wonil Koh
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, The Republic of Korea
| | - Yeoncheol Park
- Department of Acupuncture and Moxibustion, Kyung Hee University Hospital at Gangdong, Seoul, The Republic of Korea
| | - Yun Kyung Song
- Department of Korean Rehabilitation Medicine, College of Korean Medicine, Gachon University, Seongnam-si, The Republic of Korea
| | - Jae-Heung Cho
- Department of Korean Rehabilitation Medicine, College of Korean Medicine, Kyung Hee University, Dongdaemun-gu, Seoul, The Republic of Korea
| | - In-Hyuk Ha
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, The Republic of Korea
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43
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Gianola S, Andreano A, Castellini G, Li LC, Moja L, Valsecchi MG. Kinesiotaping for rotator cuff disease. Hippokratia 2017. [DOI: 10.1002/14651858.cd012720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Silvia Gianola
- IRCCS Galeazzi Orthopaedic Institute; Unit of Clinical Epidemiology; Milan Italy
- University of Milano-Bicocca; Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery; Monza Italy
| | - Anita Andreano
- University of Milano-Bicocca; Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery; Monza Italy
| | - Greta Castellini
- IRCCS Galeazzi Orthopaedic Institute; Unit of Clinical Epidemiology; Milan Italy
- University of Milan; Department of Biomedical Sciences for Health; Milan Italy
| | - Linda C Li
- University of British Columbia; Department of Physical Therapy; 5591 No. 3 Rd Richmond BC Canada V6X 2C7
| | - Lorenzo Moja
- IRCCS Galeazzi Orthopaedic Institute; Unit of Clinical Epidemiology; Milan Italy
- University of Milan; Department of Biomedical Sciences for Health; Milan Italy
| | - Maria Grazia Valsecchi
- University of Milano-Bicocca; Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery; Monza Italy
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Dørum IH, Heir S, Solheim E, Magnussen LH. Implementation of conservative treatment prior to arthroscopic subacromial decompression of the shoulder. Knee Surg Sports Traumatol Arthrosc 2017; 25:2060-2066. [PMID: 27043344 DOI: 10.1007/s00167-016-4091-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 03/14/2016] [Indexed: 12/12/2022]
Abstract
PURPOSE The aim of the study was to investigate to what extent patients undergo evidence-based conservative treatment prior to arthroscopic subacromial decompression of the shoulder. METHODS One hundred and twenty patients (65 women, 55 men, median age 53.5 years (range 28-70), referred to arthroscopic subacromial decompression at two hospitals in Norway, were consecutively included in the study. The patients completed a self-administered questionnaire including questions concerning the quantity and nature of preoperative treatment as well as the QuickDASH score. They were specifically asked for the extent of evidence-based conservative treatment, i.e. the combination of strengthening and stretching exercises at a minimum weekly amount and total duration. RESULTS One hundred and nine patients (91 %) reported having received conservative treatment guided by a physiotherapist preoperatively. The patients' main reasons for not seeing a physiotherapist were lack of trust in the treatment (N = 7) and the assumption that surgery would provide faster relief of symptoms (N = 6). Of those visiting a physiotherapist, 80 % received specific shoulder exercises. Forty-five per cent did both strengthening and stretching exercises, only 32 % did the exercises three times per week more than 2 months, and 24 % did more than 3 months as recommended. Seventy-six per cent of the patients who discontinued the prescribed exercise programme did this due to increasing pain. CONCLUSIONS Most of the patients in the current study reported having visited a physiotherapist before surgery. However, less than half of them underwent evidence-based exercise treatment, and increased pain was the main reason for not completing the prescribed exercise treatment. The results might be of clinical relevance for physiotherapists treating patients with SAPS, but also for orthopaedic surgeons doing preoperative evaluations. LEVEL OF EVIDENCE Case series, IV.
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Affiliation(s)
- Ingrid Husdal Dørum
- Department of Occupational therapy, Physiotherapy and Radiography, Bergen University College, Bergen, Norway
| | - Stig Heir
- Martina Hansens Hospital, Baerum, Norway
| | - Eirik Solheim
- Aleris Nesttun, Bergen, Norway.,Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Liv Heide Magnussen
- Department of Occupational therapy, Physiotherapy and Radiography, Bergen University College, Bergen, Norway. .,Department of Global Public Health and Primary Care, Physiotherapy Research Group, University of Bergen, Bergen, Norway.
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Babatunde OO, Jordan JL, Van der Windt DA, Hill JC, Foster NE, Protheroe J. Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PLoS One 2017; 12:e0178621. [PMID: 28640822 PMCID: PMC5480856 DOI: 10.1371/journal.pone.0178621] [Citation(s) in RCA: 207] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 05/16/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND & AIMS Musculoskeletal pain, the most common cause of disability globally, is most frequently managed in primary care. People with musculoskeletal pain in different body regions share similar characteristics, prognosis, and may respond to similar treatments. This overview aims to summarise current best evidence on currently available treatment options for the five most common musculoskeletal pain presentations (back, neck, shoulder, knee and multi-site pain) in primary care. METHODS A systematic search was conducted. Initial searches identified clinical guidelines, clinical pathways and systematic reviews. Additional searches found recently published trials and those addressing gaps in the evidence base. Data on study populations, interventions, and outcomes of intervention on pain and function were extracted. Quality of systematic reviews was assessed using AMSTAR, and strength of evidence rated using a modified GRADE approach. RESULTS Moderate to strong evidence suggests that exercise therapy and psychosocial interventions are effective for relieving pain and improving function for musculoskeletal pain. NSAIDs and opioids reduce pain in the short-term, but the effect size is modest and the potential for adverse effects need careful consideration. Corticosteroid injections were found to be beneficial for short-term pain relief among patients with knee and shoulder pain. However, current evidence remains equivocal on optimal dose, intensity and frequency, or mode of application for most treatment options. CONCLUSION This review presents a comprehensive summary and critical assessment of current evidence for the treatment of pain presentations in primary care. The evidence synthesis of interventions for common musculoskeletal pain presentations shows moderate-strong evidence for exercise therapy and psychosocial interventions, with short-term benefits only from pharmacological treatments. Future research into optimal dose and application of the most promising treatments is needed.
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Affiliation(s)
- Opeyemi O. Babatunde
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, United Kingdom
| | - Joanne L. Jordan
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, United Kingdom
| | - Danielle A. Van der Windt
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, United Kingdom
| | - Jonathan C. Hill
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, United Kingdom
| | - Nadine E. Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, United Kingdom
| | - Joanne Protheroe
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, United Kingdom
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Vincent K, Leboeuf-Yde C, Gagey O. Are degenerative rotator cuff disorders a cause of shoulder pain? Comparison of prevalence of degenerative rotator cuff disease to prevalence of nontraumatic shoulder pain through three systematic and critical reviews. J Shoulder Elbow Surg 2017; 26:766-773. [PMID: 28089260 DOI: 10.1016/j.jse.2016.09.060] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 09/17/2016] [Accepted: 09/27/2016] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS AND BACKGROUND The role of degeneration is not well understood for rotator cuff pain. If age-related degenerative changes would be the cause of symptoms, degeneration would precede or concur with self-reported pain. We performed 3 systematic literature reviews. Our objectives were to determine the prevalence estimates for rotator cuff partial or complete tears (1) in cadavers and (2) in the general population and (3) to estimate the incidence/prevalence of self-reported nontraumatic shoulder pain in the general population in order to compare their respective age-related profiles. METHODS We searched PubMed and ScienceDirect, including 2015, for cadaveric studies and transverse and longitudinal studies of the general population reporting the incidence/prevalence of rotator cuff disorders or nontraumatic shoulder pain, or both, according to age. The review process followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Results were interpreted visually. RESULTS We found 6 cadaveric studies, 2 studies from the general population reporting complete tears, and 10 articles on nontraumatic shoulder pain in the general population that met our criteria. The profiles of degeneration vs. pain were very similar in early years. Although degenerative rotators cuff lesions increased gradually after 50 years, the incidence/prevalence of nontraumatic shoulder pain decreased after 65 years. CONCLUSION The profile of age-related degenerative rotator cuff disorders fails to correlate systematically with self-reported nontraumatic shoulder pain, particularly in older age; thus, it appears that degeneration should not be considered the primary source of the pain. Physical activity may play an important role in the production of the pain, a theory that warrants further study.
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Affiliation(s)
- Karl Vincent
- Ecole Doctorale 566, Sciences du Sport et du Mouvement Humain, Orsay, France; Institut Franco-Européen de Chiropraxie, Ivry-Sur-Seine, France.
| | - Charlotte Leboeuf-Yde
- Ecole Doctorale 566, Sciences du Sport et du Mouvement Humain, Orsay, France; The Spine Center of Southern Denmark, Hospital Lillebælt and Institute of Regional Health Research, University of Southern Denmark, Middelfart, Denmark
| | - Olivier Gagey
- Ecole Doctorale 566, Sciences du Sport et du Mouvement Humain, Orsay, France; Institut Franco-Européen de Chiropraxie, Ivry-Sur-Seine, France
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Shire AR, Stæhr TAB, Overby JB, Bastholm Dahl M, Sandell Jacobsen J, Høyrup Christiansen D. Specific or general exercise strategy for subacromial impingement syndrome-does it matter? A systematic literature review and meta analysis. BMC Musculoskelet Disord 2017; 18:158. [PMID: 28416022 PMCID: PMC5393017 DOI: 10.1186/s12891-017-1518-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 04/04/2017] [Indexed: 02/01/2023] Open
Abstract
Background Exercise is frequently suggested as a treatment option for patients presenting with symptoms of subacromial impingement syndrome. Some would argue implementing a specific exercise strategy with special focus on correction of kinematic deficits would be superior to general exercise strategy. There is however a lack of evidence comparing such exercise strategies to determine which is the most effective in the treatment of subacromial impingement syndrome. The aim of this review is to evaluate whether implementing specific exercise strategies involving resistive exercises are more effective than a general exercise strategy for the treatment of patients with subacromial impingement syndrome. Methods Randomized controlled trials were identified through an electronic search on PubMed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science and PEDro. In addition, article reference lists and Clinicaltrials.gov were searched. Studies were considered eligible if they included interventions with resistive specific exercises as compared to general resistance exercise. Four reviewers assessed risk of bias and methodological quality guided by Cochrane recommendations. Results were synthesised qualitatively or quantitatively, where appropriate. Results Six randomized controlled trials were included with 231 participants who experienced symptoms of subacromial impingement syndrome. Four studies evaluated the effectiveness of specific scapular exercise strategy and two studies evaluated the effectiveness of specific proprioceptive strategy. Five studies were of moderate quality and one study was of low quality. No consistent statistical significant differences in outcomes between treatment groups were reported in the studies. Standardized mean difference (SMD) for pain was SMD −0.19 (95% CI −0.61, 0.22) and SMD 0.30 (95% CI −0.16, 0.76) for function. Conclusions There is insufficient evidence to support or refute the effectiveness of specific resistive exercise strategies in the rehabilitation of subacromial impingement syndrome. More high quality research is needed to accurately assess this. This review provides suggestions on how to improve the methodological design of future studies in this area. Electronic supplementary material The online version of this article (doi:10.1186/s12891-017-1518-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alison R Shire
- Department of Physiotherapy, VIA University College, Hedeager 2, Aarhus N, Denmark.
| | - Thor A B Stæhr
- Department of Physiotherapy, VIA University College, Hedeager 2, Aarhus N, Denmark
| | - Jesper B Overby
- Department of Physiotherapy, VIA University College, Hedeager 2, Aarhus N, Denmark
| | | | | | - David Høyrup Christiansen
- Danish Ramazzini Centre, Department of Occupational Medicine, University Research Clinic, Regional Hospital West Jutland, Herning, Denmark
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Pastora-Bernal JM, Martín-Valero R, Barón-López FJ, García-Gómez O. Effectiveness of telerehabilitation programme following surgery in shoulder impingement syndrome (SIS): study protocol for a randomized controlled non-inferiority trial. Trials 2017; 18:82. [PMID: 28231815 PMCID: PMC5324280 DOI: 10.1186/s13063-017-1822-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 01/28/2017] [Indexed: 12/22/2022] Open
Abstract
Background Shoulder pain is common in society, with high prevalence in the general population. Shoulder impingement syndrome (SIS) is the most frequent cause. Patients suffer pain, muscle weakness and loss of movement in the affected joint. Initial treatment is predominantly conservative. The surgical option has high success rates and is often used when conservative strategy fails. Traditional physiotherapy and post-operative exercises are needed for the recovery of joint range, muscle strength, stability and functionality. Telerehabilitation programmes have shown positive results in some orthopaedic conditions after surgery. Customized telerehabilitation intervention programmes should be developed to recover shoulder function after SIS surgery. The objective of this study is to evaluate the feasibility and effectiveness of a telerehabilitation intervention compared with usual care in patients after subacromial decompression surgery. Methods We will compare an intervention group receiving videoconferences and a telerehabilitation programme to a control group receiving traditional physiotherapy intervention in a single-blind, randomized controlled non-inferiority trial study design. Discussion Through this study, we will further develop our preliminary data set and practical experience with the telerehabilitation programmes to evaluate their effectiveness and compare this with traditional intervention. We will also explore patient satisfaction and cost-effectiveness. Patient enrolment is ongoing. Trial registration ClinicalTrials.gov, NCT02909920. 14 September 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1822-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jose-Manuel Pastora-Bernal
- Health Science, Degree of Physiotherapy, University of Málaga, Málaga, Spain. .,Department of Physiotherapy, Faculty of Health Sciences C/Arquitecto Francisco Peñalosa Ampliación del C. Teatinos, 29071, Málaga, Spain.
| | - Rocío Martín-Valero
- Department of Physiotherapy, Faculty of Nursery and Physiotherapy, PhD Lecture University of Cádiz, Cádiz, Spain
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Jo YH, Lee KH, Kim SJ, Kim J, Lee BG. National Trends in Surgery for Rotator Cuff Disease in Korea. J Korean Med Sci 2017; 32:357-364. [PMID: 28049250 PMCID: PMC5220005 DOI: 10.3346/jkms.2017.32.2.357] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 10/16/2016] [Indexed: 12/22/2022] Open
Abstract
The objective of this study was to investigate the national trends in rotator cuff surgery in Korea and analyze hospital type-specific trends. We analyzed a nationwide database acquired from the Korean Health Insurance Review and Assessment Service (HIRA) from 2007 to 2015. International Classification of Diseases, 10th revision (ICD-10) codes, procedure codes, and arthroscopic device code were used to identify patients who underwent surgical treatment for rotator cuff disease. A total of 383,719 cases of rotator cuff surgeries were performed from 2007 to 2015. The mean annual percentage change in the age-adjusted rate of rotator cuff surgery per population of 100,000 persons rapidly increased from 2007 to 2012 (53.3%, P < 0.001), while that between 2012 to 2015 remained steady (2.3%, P = 0.34). The proportion of arthroscopic surgery among all rotator cuff surgeries steadily rose from 89.9% in 2007 to 96.8% in 2015 (P < 0.001). In terms of hospital types, the rate of rotator cuff surgery increased to the greatest degree in hospitals with 30-100 inpatient beds, and isolated acromioplasty procedure accounted for a larger proportion of the rotator cuff surgeries in small hospitals and clinics compared to large hospitals. Overall, our findings indicate that cases of rotator cuff surgery have increased rapidly recently in Korea, of which arthroscopic surgeries account for the greatest proportion. While rotator cuff surgery is a popular procedure that is commonly performed even in small hospitals, there was a difference in the component ratio of the procedure code in accordance with hospital type.
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Affiliation(s)
- Young Hoon Jo
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Kwang Hyun Lee
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Sung Jae Kim
- Department of Orthopaedic Surgery, KEPCO Medical Center, Seoul, Korea
| | - Jaedong Kim
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Bong Gun Lee
- Department of Orthopaedic Surgery, Hanyang University College of Medicine, Seoul, Korea.
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Aagaard T, Lund H, Juhl C. Optimizing literature search in systematic reviews - are MEDLINE, EMBASE and CENTRAL enough for identifying effect studies within the area of musculoskeletal disorders? BMC Med Res Methodol 2016; 16:161. [PMID: 27875992 PMCID: PMC5120411 DOI: 10.1186/s12874-016-0264-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 11/14/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND When conducting systematic reviews, it is essential to perform a comprehensive literature search to identify all published studies relevant to the specific research question. The Cochrane Collaborations Methodological Expectations of Cochrane Intervention Reviews (MECIR) guidelines state that searching MEDLINE, EMBASE and CENTRAL should be considered mandatory. The aim of this study was to evaluate the MECIR recommendations to use MEDLINE, EMBASE and CENTRAL combined, and examine the yield of using these to find randomized controlled trials (RCTs) within the area of musculoskeletal disorders. METHODS Data sources were systematic reviews published by the Cochrane Musculoskeletal Review Group, including at least five RCTs, reporting a search history, searching MEDLINE, EMBASE, CENTRAL, and adding reference- and hand-searching. Additional databases were deemed eligible if they indexed RCTs, were in English and used in more than three of the systematic reviews. Relative recall was calculated as the number of studies identified by the literature search divided by the number of eligible studies i.e. included studies in the individual systematic reviews. Finally, cumulative median recall was calculated for MEDLINE, EMBASE and CENTRAL combined followed by the databases yielding additional studies. RESULTS Deemed eligible was twenty-three systematic reviews and the databases included other than MEDLINE, EMBASE and CENTRAL was AMED, CINAHL, HealthSTAR, MANTIS, OT-Seeker, PEDro, PsychINFO, SCOPUS, SportDISCUS and Web of Science. Cumulative median recall for combined searching in MEDLINE, EMBASE and CENTRAL was 88.9% and increased to 90.9% when adding 10 additional databases. CONCLUSION Searching MEDLINE, EMBASE and CENTRAL was not sufficient for identifying all effect studies on musculoskeletal disorders, but additional ten databases did only increase the median recall by 2%. It is possible that searching databases is not sufficient to identify all relevant references, and that reviewers must rely upon additional sources in their literature search. However further research is needed.
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Affiliation(s)
- Thomas Aagaard
- Department of Physiotherapy, Holbaek University Hospital, Holbaek, Denmark
- Research Unit for Musculoskeletal Function and Physiotherapy, Institute for Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Hans Lund
- Research Unit for Musculoskeletal Function and Physiotherapy, Institute for Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Center for Evidence-based practice, Bergen University College, Bergen, Norway
| | - Carsten Juhl
- Research Unit for Musculoskeletal Function and Physiotherapy, Institute for Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Department of Rehabilitation, Copenhagen University Hospital, Herlev, Gentofte, Denmark
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