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McFarland EG, Brand JC, Ring D. Clinical Faceoff: Is Preventative Surgery a Good Idea for Patients With Rotator Cuff Tendinopathy? Clin Orthop Relat Res 2023; 481:1486-1490. [PMID: 37404134 PMCID: PMC10344515 DOI: 10.1097/corr.0000000000002752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/05/2023] [Indexed: 07/06/2023]
Affiliation(s)
- Edward G. McFarland
- Department of Orthopaedic Surgery, Division of Shoulder Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jefferson C. Brand
- Heartland Orthopedic Specialists, 111 17th Ave E, Ste. 101, Alexandria, MN, USA
| | - David Ring
- Associate Dean for Comprehensive Care, Dell Medical School, Department of Surgery and Perioperative Care, Austin, TX, USA
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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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Habechian FAP, Flores Quezada ME, Cools AM, Kjaer BH, Cuevas Cid RI, Zanca GG. Shoulder-specific rehabilitation combined with aerobic exercises versus solely shoulder-specific rehabilitation in patients with type 2 diabetes mellitus: study protocol for a randomized controlled superiority trial. Trials 2022; 23:678. [PMID: 35978380 PMCID: PMC9387007 DOI: 10.1186/s13063-022-06647-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 08/07/2022] [Indexed: 11/17/2022] Open
Abstract
Background Musculoskeletal disorders are very common in patients with diabetes mellitus (DM). The upper limb is one of the regions that is most frequently affected generally presenting limited joint mobility, pain, and a decreased muscle strength. Most clinical trials with a focus on shoulder musculoskeletal rehabilitation are carried out in patients who do not present DM. Thus, the purpose of the present study is to compare the effects of two distinct treatment protocols (conventional shoulder musculoskeletal rehabilitation combined with aerobic exercises versus solely conventional shoulder musculoskeletal rehabilitation) on shoulder pain, function, strength, kinematics, and supraspinatus tendon thickness in patients with type 2 DM after 12 weeks of intervention and a subsequent follow-up at week 20. Methods A randomized controlled superiority trial will be conducted. Participants with a clinical diagnosis of type 2 DM of both sexes, age between 40 and 70 years, presenting shoulder pain will be randomly assigned to one of the following groups: (1) conventional shoulder musculoskeletal rehabilitation combined with aerobic exercises; (2) solely conventional shoulder musculoskeletal rehabilitation. All individuals will be evaluated before starting the treatment protocol (baseline) and at the end of treatment (post 12 weeks) and as a follow-up at 20 weeks. The shoulder function assessed by the SPADI (Shoulder Pain and Disability Index) questionnaire will be considered as primary outcome; the secondary outcome will be shoulder pain, measured with NPRS scales. Other outcomes will include range of motion, measured using a digital inclinometer; isometric shoulder muscle strength, measured using a manual muscle dynamometer; shoulder kinematics, measured using three-dimensional inertial units measurement; supraspinatus tendon thickness, measured using an ultrasound; AGE accumulation, using a skin autofluorescence measurement; and HbA1c (hemoglobin a1c), fasting glucose and lipid profile measured by a simple blood test. Discussion DM is a highly prevalent disease and a public health problem worldwide, and the upper extremity musculoskeletal disorders in DM are barely recognized and largely underestimated. In this way, it would be interesting to analyze if the combination of aerobic exercises with conventional musculoskeletal rehabilitation protocols could generate better results in the functionality, pain, mobility and an improvement in the biochemical aspects related to the hyperglycemia of these patients compared to solely the conventional musculoskeletal rehabilitation. Trial registration ClinicalTrials.gov NCT04817514. Registered on March 26, 2021.
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Affiliation(s)
- Fernanda A P Habechian
- Laboratory of Clinical Research in Kinesiology, Department of Kinesiology, Universidad Católica del Maule, Casa Central: Avda. San Miguel, 3605, Talca, Chile.
| | - Mauricio E Flores Quezada
- Laboratory of Clinical Research in Kinesiology, Department of Kinesiology, Universidad Católica del Maule, Casa Central: Avda. San Miguel, 3605, Talca, Chile
| | - Ann M Cools
- Faculty Medicine and Health Sciences, Department of Rehabilitation Science and Physiotherapy, Ghent University, Campus Heymans (UZ Ghent), Building B3 - Second floor, De Pintelaan 185, 9000, Ghent, Belgium
| | - Birgitte Hougs Kjaer
- Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg University Hospitals, Bispebjerg Bakke 23, DK-2400, Copenhagen, NV, Denmark
| | - Rodrigo I Cuevas Cid
- Laboratory of Clinical Research in Kinesiology, Department of Kinesiology, Universidad Católica del Maule, Casa Central: Avda. San Miguel, 3605, Talca, Chile
| | - Gisele G Zanca
- Postgraduate Program in Aging Sciences and Postgraduate Program in Physical Education, São Judas Tadeu University, Rua Taquari, 546. Mooca, São Paulo, 03166-000, Brazil
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Bourke J, Skouteris H, Hatzikiriakidis K, Fahey D, Malliaras P. Use of Behavior Change Techniques Alongside Exercise in the Management of Rotator Cuff-Related Shoulder Pain: A Scoping Review. Phys Ther 2022; 102:6482025. [PMID: 34972867 DOI: 10.1093/ptj/pzab290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 08/20/2021] [Accepted: 11/19/2021] [Indexed: 02/09/2023]
Abstract
OBJECTIVES The aims of this scoping review were to: (1) determine the frequency and types of behavior change techniques (BCTs) and education utilized in trials investigating exercise interventions for rotator cuff related shoulder pain (RCRSP); (2) subcategorize the BCTs and education found in the trials to summarize all behavior change approaches reported by trials; and (3) compare the frequency, types, and subcategories of BCTs and education utilized in the clinical guidelines for managing RCRSP between the trials. METHODS Data sources included Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE, CINAHL Plus, Google Scholar and PubMed, which were searched from inception to June 2020. Trials assessing exercise interventions for RCRSP were included. Three authors independently determined eligibility and extracted data. The frequency and types of BCTs and education in the trials and clinical practice guidelines were reported and compared descriptively. Two authors assessed the content of the BCTs to develop subcategories. RESULTS Most trials reported including at least 1 type of BCT (89.2%), which was most commonly feedback and monitoring (78.5%). There were many different approaches to the BCTs and education; for example, feedback and monitoring was subcategorized into supervised exercise, exercise monitoring, and feedback through external aids, such as mirrors. Clinical guidelines recommend supervision, goal setting, activity modification, pain management recommendations, information about the condition, and exercise education. CONCLUSION Although over two-thirds of trials reported including a BCT alongside exercise interventions for RCRSP, the breadth of these interventions is limited (supervision is the only common one). Future trialists should consider using any type of BCT that may improve exercise adherence and outcomes. IMPACT The findings of this review have: (1) identified gaps in the literature; and (2) contributed to the design of future exercise interventions for RCRSP.
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Affiliation(s)
- Jaryd Bourke
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Victoria, Australia
| | - Helen Skouteris
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Kostas Hatzikiriakidis
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - David Fahey
- Enhance Sports Performance and Rehabilitation, Maribyrnong, Victoria, Australia
| | - Peter Malliaras
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Victoria, Australia
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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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Waterman BR, Newgren J, Gowd AK, Cabarcas B, Lansdown D, Bach BR, Cole BJ, Romeo AA, Verma NN. Randomized Trial of Arthroscopic Rotator Cuff With or Without Acromioplasty: No Difference in Patient-Reported Outcomes at Long-Term Follow-Up. Arthroscopy 2021; 37:3072-3078. [PMID: 33940126 DOI: 10.1016/j.arthro.2021.04.041] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/12/2021] [Accepted: 04/18/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate long-term patient-reported outcomes and revision surgery after arthroscopic rotator cuff repair with or without acromioplasty. METHODS Between 2007 and 2011, prospectively enrolled patients undergoing arthroscopic repair for full-thickness rotator cuff tears, with any acromial morphology, were randomized into either acromioplasty or nonacromioplasty groups. Patients with revision surgery, subscapularis involvement, advanced neurologic conditions, or death were excluded. Baseline and long-term follow-up questionnaires, including the American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (SST), University of California-Los Angeles (UCLA), Visual Analog Scale (VAS) for pain, and Constant scores were obtained. Rates of symptomatic retear, revision rotator cuff surgery, or secondary reoperation were recorded. Averages with standard deviation were calculated, and t-tests were used to compare outcomes of interest between cohorts. RESULTS In total, 69 of 90 patients (76.7%) were available at 92.4 months (± 10.5). There were 23 of 32 patients in the acromioplasty cohort and 24 of 37 patients in the nonacromioplasty cohort. Mean age for the nonacromioplasty cohort was 56.9 (± 7.6) years, whereas acromioplasty was 59.6 (± 6.8) years. Comparison of baseline demographics and intraoperative information revealed no significant differences, including age, sex, Workers' Compensation, acute mechanism of injury, tear size, degree of retraction, and surgical technique (e.g., single- vs. double-row). At final follow-up, there were no statistically significant differences according to ASES (P = .33), VAS pain (P = 0.79), Constant (P = .17), SST (P = .05), UCLA (P = .19), and Short Form-12 (SF-12) (P = .79) in patients with and without acromioplasty. Two patients with acromioplasty (5.6%) and 3 patients without acromioplasty (9.1%) sustained atraumatic recurrent rotator cuff tear with secondary repair (P = .99), and there was no significant difference in retear rates or patient-reported outcome measures by acromial morphology. CONCLUSIONS This randomized trial, with mean 7.5-year follow-up, found no difference in validated patient-reported outcomes, retear rate, or revision surgery rate between patients undergoing rotator cuff repair with or without acromioplasty. LEVEL OF EVIDENCE II, prospective randomized controlled trial.
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Affiliation(s)
- Brian R Waterman
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A..
| | - Jon Newgren
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
| | - Anirudh K Gowd
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
| | - Brandon Cabarcas
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
| | - Drew Lansdown
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
| | - Bernard R Bach
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
| | - Brian J Cole
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
| | - Anthony A Romeo
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
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Beard DJ, Campbell MK, Blazeby JM, Carr AJ, Weijer C, Cuthbertson BH, Buchbinder R, Pinkney T, Bishop FL, Pugh J, Cousins S, Harris I, Lohmander LS, Blencowe N, Gillies K, Probst P, Brennan C, Cook A, Farrar-Hockley D, Savulescu J, Huxtable R, Rangan A, Tracey I, Brocklehurst P, Ferreira ML, Nicholl J, Reeves BC, Hamdy F, Rowley SC, Lee N, Cook JA. Placebo comparator group selection and use in surgical trials: the ASPIRE project including expert workshop. Health Technol Assess 2021; 25:1-52. [PMID: 34505829 PMCID: PMC8450778 DOI: 10.3310/hta25530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The use of placebo comparisons for randomised trials assessing the efficacy of surgical interventions is increasingly being considered. However, a placebo control is a complex type of comparison group in the surgical setting and, although powerful, presents many challenges. OBJECTIVES To provide a summary of knowledge on placebo controls in surgical trials and to summarise any recommendations for designers, evaluators and funders of placebo-controlled surgical trials. DESIGN To carry out a state-of-the-art workshop and produce a corresponding report involving key stakeholders throughout. SETTING A workshop to discuss and summarise the existing knowledge and to develop the new guidelines. RESULTS To assess what a placebo control entails and to assess the understanding of this tool in the context of surgery is considered, along with when placebo controls in surgery are acceptable (and when they are desirable). We have considered ethics arguments and regulatory requirements, how a placebo control should be designed, how to identify and mitigate risk for participants in these trials, and how such trials should be carried out and interpreted. The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Surgical placebos might be most appropriate when there is poor evidence for the efficacy of the procedure and a justified concern that results of a trial would be associated with a high risk of bias, particularly because of the placebo effect. CONCLUSIONS The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Feasibility work is recommended to optimise the design and implementation of randomised controlled trials. An outline for best practice was produced in the form of the Applying Surgical Placebo in Randomised Evaluations (ASPIRE) guidelines for those considering the use of a placebo control in a surgical randomised controlled trial. LIMITATIONS Although the workshop participants involved international members, the majority of participants were from the UK. Therefore, although every attempt was made to make the recommendations applicable to all health systems, the guidelines may, unconsciously, be particularly applicable to clinical practice in the UK NHS. FUTURE WORK Future work should evaluate the use of the ASPIRE guidelines in making decisions about the use of a placebo-controlled surgical trial. In addition, further work is required on the appropriate nomenclature to adopt in this space. FUNDING Funded by the Medical Research Council UK and the National Institute for Health Research as part of the Medical Research Council-National Institute for Health Research Methodology Research programme.
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Jane M Blazeby
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Charles Weijer
- Departments of Medicine, Epidemiology and Biostatistics, and Philosophy, Western University, London, ON, Canada
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Thomas Pinkney
- Academic Department of Surgery, University of Birmingham, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Felicity L Bishop
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jonathan Pugh
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Sian Cousins
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Ian Harris
- Faculty of Medicine, South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund University, Lund, Sweden
| | - Natalie Blencowe
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Andrew Cook
- Wessex Institute, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Julian Savulescu
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Richard Huxtable
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Health Sciences, University of York, York, UK
| | - Irene Tracey
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Manuela L Ferreira
- Faculty of Medicine and Health, Institute of Bone and Joint Research, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Jon Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Barnaby C Reeves
- Clinical Trials Evaluation Unit Bristol Medical School, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Freddie Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | - Naomi Lee
- Editorial Department, The Lancet, London, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Hall K, Grinstead A, Lewis JS, Mercer C, Moore A, Ridehalgh C. Rotator cuff related shoulder pain. Describing home exercise adherence and the use of behavior change interventions to promote home exercise adherence: a systematic review of randomized controlled trials. PHYSICAL THERAPY REVIEWS 2021. [DOI: 10.1080/10833196.2021.1935106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Kevin Hall
- Physiotherapy Musculoskeletal Outpatients, Western Sussex Hospitals NHS Foundation Trust, West Sussex, United Kingdom
| | - Anthony Grinstead
- Physiotherapy Musculoskeletal Outpatients, Western Sussex Hospitals NHS Foundation Trust, West Sussex, United Kingdom
| | - Jeremy S. Lewis
- School of Health and Social Work, University of Hertfordshire, Hertfordshire, United Kingdom
- Therapy Department, Central London Community Healthcare National Health Service Trust, London, United Kingdom
- Department of Physical Therapy & Rehabilitation Science, College of Health Sciences, Qatar University, Doha, Qatar
| | - Chris Mercer
- Physiotherapy Musculoskeletal Outpatients, Western Sussex Hospitals NHS Foundation Trust, West Sussex, United Kingdom
| | - Ann Moore
- School of Health Sciences, University of Brighton, Eastbourne, East Sussex, United Kingdom
| | - Colette Ridehalgh
- School of Health Sciences, University of Brighton, Eastbourne, United Kingdom
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Kanto K, Lähdeoja T, Paavola M, Aronen P, Järvinen TLN, Jokihaara J, Ardern CL, Karjalainen TV, Taimela S. Minimal important difference and patient acceptable symptom state for pain, Constant-Murley score and Simple Shoulder Test in patients with subacromial pain syndrome. BMC Med Res Methodol 2021; 21:45. [PMID: 33676417 PMCID: PMC7937213 DOI: 10.1186/s12874-021-01241-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/24/2021] [Indexed: 12/15/2022] Open
Abstract
Background The results of clinical trials should be assessed for both statistical significance and importance of observed effects to patients. Minimal important difference (MID) is a threshold denoting a difference that is important to patients. Patient acceptable symptom state (PASS) is a threshold above which patients feel well. Objective To determine MID and PASS for common outcome instruments in patients with subacromial pain syndrome (SAPS). Methods We used data from the FIMPACT trial, a randomised controlled trial of treatment for SAPS that included 193 patients. The outcomes were shoulder pain at rest and on arm activity, both measured with the 0–100 mm visual analogue scale (VAS), the Constant-Murley score (CS), and the Simple Shoulder Test (SST). The transition question was a five-point global rating of change. We used three anchor-based methods to determine the MID for improvement: the receiver operating characteristic (ROC) curve, the mean difference of change and the mean change methods. For the PASS, we used the ROC and 75th percentile methods and calculated estimates using two different anchor question thresholds. Results Different MID methods yielded different estimates. The ROC method yielded the smallest estimates for MID: 20 mm for shoulder pain on arm activity, 10 points for CS and 1.5 points for SST, with good to excellent discrimination (areas under curve (AUCs) from 0.86 to 0.94). We could not establish a reliable MID for pain at rest. The PASS estimates were consistent between methods. The ROC method PASS thresholds using a conservative anchor question threshold were 2 mm for pain at rest, 9 mm for pain on activity, 80 points for CS and 11 points for SST, with AUCs from 0.74 to 0.83. Conclusion We recommend the smallest estimate from different methods as the MID, because it is very unlikely that changes smaller than the smallest MID estimate are important to patients: 20 mm for pain VAS on arm activity, 10 points for CS and 1.5 points for SST. We recommend PASS estimates of 9 mm for pain on arm activity, 80 points for CS, and 11 points for SST. Trial registration ClinicalTrials.gov NCT00428870 (first registered January 29, 2007). Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01241-w.
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Affiliation(s)
- Kari Kanto
- Finnish Centre for Evidence-Based Orthopaedics (FICEBO), Department of Orthopaedics and Traumatology, Tampere University Hospital, TAYS Hatanpää, Hatanpäänkatu 24, 33900, Tampere, Finland
| | - Tuomas Lähdeoja
- Finnish Centre for Evidence-Based Orthopaedics (FICEBO), Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, HUS, 00029, Helsinki, Finland
| | - Mika Paavola
- Finnish Centre for Evidence-Based Orthopaedics (FICEBO), Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, HUS, 00029, Helsinki, Finland
| | - Pasi Aronen
- Biostatistics Unit, Faculty of Medicine at University of Helsinki and Helsinki University Hospital, Tukholmankatu 8B, 00290, Helsinki, Finland
| | - Teppo L N Järvinen
- Finnish Centre for Evidence-Based Orthopaedics (FICEBO), Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, HUS, 00029, Helsinki, Finland
| | - Jarkko Jokihaara
- Finnish Centre for Evidence-Based Orthopaedics (FICEBO), Department of Hand and Microsurgery, Tampere University Hospital, Elämänaukio 2, 33520, Tampere, Finland
| | - Clare L Ardern
- Finnish Centre for Evidence-Based Orthopaedics (FICEBO), Division of Physiotherapy, Karolinska Institute, H1 Fysioterapi, 17177, Stockholm, Sweden
| | - Teemu V Karjalainen
- Finnish Centre for Evidence-Based Orthopaedics (FICEBO), Central Finland Central Hospital, Jyväskylä, Keskussairaalantie 19, 40620, Jyväskylä, Finland
| | - Simo Taimela
- Finnish Centre for Evidence-Based Orthopaedics (FICEBO), Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, HUS, 00029, Helsinki, Finland.
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Paavola M, Kanto K, Ranstam J, Malmivaara A, Inkinen J, Kalske J, Savolainen V, Sinisaari I, Taimela S, Järvinen TL. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: a 5-year follow-up of a randomised, placebo surgery controlled clinical trial. Br J Sports Med 2020; 55:99-107. [PMID: 33020137 PMCID: PMC7788208 DOI: 10.1136/bjsports-2020-102216] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2020] [Indexed: 12/15/2022]
Abstract
Objectives To assess the long-term efficacy of arthroscopic subacromial decompression (ASD) by comparing it with diagnostic arthroscopy (primary comparison), a placebo surgical intervention, and with a non-operative alternative, exercise therapy (secondary comparison). Methods We conducted a multicentre, three group, randomised, controlled superiority trial. We included 210 patients aged 35–65 years, who had symptoms consistent with shoulder impingement syndrome for more than 3 months. 175 participants (83%) completed the 5 years follow-up. Patient enrolment began on 1 February 2005 and the 5-year follow-up was completed by 10 October 2018. The two primary outcomes were shoulder pain at rest and on arm activity measured with Visual Analogue Scale (VAS). Minimally important difference (MID) was set at 15. We used a mixed-model repeated measurements analysis of variance with participant as a random factor, the baseline value as a covariate and assuming a covariance structure with compound symmetry. Results In the primary intention to treat analysis (ASD vs diagnostic arthroscopy), there were no between-group differences that exceeded the MID for the primary outcomes at 5 years: the mean difference between groups (ASD minus diagnostic arthroscopy) in pain VAS were −2.0 (95% CI −8.5 to 4.6; p=0.56) at rest and −8.0 (−17.3 to 1.3; p=0.093) on arm activity. There were no between-group differences in the secondary outcomes or adverse events that exceeded the MID. In our secondary comparison (ASD vs exercise therapy), the mean differences between groups (ASD minus exercise therapy) in pain VAS were 1.0 (−5.6 to 7.6; p=0.77) at rest and −3.9 (−12.8 to 5.1; p=0.40) on arm activity. There were no significant between-group differences for the secondary outcomes or adverse events. Conclusions ASD provided no benefit over diagnostic arthroscopy (or exercise therapy) at 5 years for patients with shoulder impingement syndrome.
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Affiliation(s)
- Mika Paavola
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Kari Kanto
- TAYS Hatanpää/Department of Orthopedics and Traumatology, Tampere University Hospital, Tampere, Finland.,Finnish Centre for Evidence-Based Orthopaedics (FICEBO), Department of Orthopaedics and Traumatology, University of Helsinki, Helsinki, Finland
| | | | - Antti Malmivaara
- Centre for Health and Social Economics - CHESS, National Institute for Health and Welfare, Helsinki, Finland
| | | | - Juha Kalske
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Vesa Savolainen
- Department of Orthopaedics and Traumatology, Pohjola Hospital, Helsinki, Finland
| | | | - Simo Taimela
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland.,Finnish Centre for Evidence-Based Orthopaedics (FICEBO), Department of Orthopaedics and Traumatology, University of Helsinki, Helsinki, Finland
| | - Teppo L Järvinen
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland.,Finnish Centre for Evidence-Based Orthopaedics (FICEBO), Department of Orthopaedics and Traumatology, University of Helsinki, Helsinki, Finland
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11
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Sochacki KR, Mather RC, Nwachukwu BU, Dong D, Nho SJ, Cote MP, Harris JD. Sham Surgery Studies in Orthopaedic Surgery May Just Be a Sham: A Systematic Review of Randomized Placebo-Controlled Trials. Arthroscopy 2020; 36:2750-2762.e2. [PMID: 32417564 DOI: 10.1016/j.arthro.2020.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the limitations of randomized sham surgery-controlled trials in orthopaedic sports medicine and fidelity of the trials' conclusions. METHODS Randomized placebo surgery-controlled trials in orthopaedic sports medicine were included in this Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided systematic review. Several aspects of investigation design and conduct were analyzed: genetic analysis for propensity to placebo response, equipoise of informed consent process, geography of trial subjects, percentage of eligible subjects willing to be randomized, changes from protocol publication to results publication, and perioperative complications. RESULTS Seven sham surgery-controlled trials (845 subjects [370 knees, 449 shoulders, 26 elbows]; 5 from Europe, 1 from North America, and 1 from Australia; all superiority model, efficacy design) were analyzed. There were consistent methodologic deficiencies across studies. No studies reported genetic analysis of susceptibility to placebo response. Three studies (43%) were underpowered. Crossover rates ranged from 8% to 36%, which led to un-blinding in up to 100% of subjects. There were low enrollment rates of eligible subjects (up to 57% refused randomization). Follow-up was short term (2 years or less in all but one study). Complication rates ranged from 0% to 12.5%, with complications occurring in both groups (no significant difference between groups in any study). CONCLUSIONS Randomized sham-controlled studies in orthopaedic sports medicine have significant methodologic deficiencies that may invalidate their conclusions. Randomized trial design (with or without placebo control) may be optimized through the inclusion of per-protocol analysis, blinding index, equivalence or noninferiority trial design, and a nontreatment group. LEVEL OF EVIDENCE Level II Systematic Review of Level II studies.
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Affiliation(s)
- Kyle R Sochacki
- Houston Methodist Orthopedic and Sports Medicine, Houston, Texas, U.S.A
| | - Richard C Mather
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, U.S.A
| | | | - David Dong
- Houston Methodist Orthopedic and Sports Medicine, Houston, Texas, U.S.A
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Mark P Cote
- UConn Musculoskeletal Institute at UConn Health, Farmington, Connecticut, U.S.A
| | - Joshua D Harris
- Houston Methodist Orthopedic and Sports Medicine, Houston, Texas, U.S.A..
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12
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Cousins S, Blencowe NS, Tsang C, Lorenc A, Chalmers K, Carr AJ, Campbell MK, Cook JA, Beard DJ, Blazeby JM. Reporting of key methodological issues in placebo-controlled trials of surgery needs improvement: a systematic review. J Clin Epidemiol 2020; 119:109-116. [PMID: 31786153 PMCID: PMC7066579 DOI: 10.1016/j.jclinepi.2019.11.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/12/2019] [Accepted: 11/24/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To examine key methodological considerations for using a placebo intervention in randomized controlled trials (RCTs) evaluating invasive procedures, including surgery. STUDY DESIGN AND SETTING RCTs comparing an invasive procedure with a placebo were included in this systematic review. Articles published from database inception to December 31, 2017, were retrieved from Ovid MEDLINE, Ovid EMBASE and CENTRAL electronic databases, by handsearching references and expert knowledge. Data on trial characteristics (clinical area, nature of invasive procedure, number of patients and centers) and key methodological (rationale for using placebos, minimization of risk, information provision, offering the treatment intervention to patients randomized to placebo, delivery of cointerventions, and intervention standardization and fidelity) were extracted and summarized descriptively. RESULTS One hundred thirteen articles reporting 96 RCTs were identified. Most were conducted in gastrointestinal surgery (n = 40, 42%) and evaluated minimally invasive procedures (n = 44, 46%). Over two-thirds randomized fewer than 100 patients (n = 65, 68%) and a third were single center (n = 31, 32%). A third (n = 33, 34%) did not report a rationale for using a placebo. Most common strategies to minimize patient risk were operator skill (n = 22, 23%) and independent data monitoring (n = 28, 29%). Provision of patient information regarding placebo use was infrequently reported (n = 11, 11%). Treatment interventions were offered to patients randomized to placebo in 43 trials (45%). Cointerventions were inconsistently reported, but 64 trials (67%) stated that anesthesia was matched between groups. Attempts to standardize interventions and monitor their delivery were reported in n = 7, (7%) and n = 4, (4%) trials, respectively. CONCLUSION Most placebo-controlled trials in surgery evaluate minor surgical procedures and currently there is inconsistent reporting of key trial methods. There is a need for guidance to optimize the transparency of trial reporting in this area.
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Affiliation(s)
- Sian Cousins
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK.
| | - Natalie S Blencowe
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK; Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Carmen Tsang
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Ava Lorenc
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Katy Chalmers
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Headington, Oxford, UK; National Institute of Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | | | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Headington, Oxford, UK; National Institute of Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Headington, Oxford, UK; National Institute of Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | - Jane M Blazeby
- National Institute of Health Research (NIHR), Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Surgical Innovation theme and the Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK; Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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13
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Rueckl K, Ernstbrunner L, Reichel T, Bouaicha S, Barthel T, Rudert M, Plumhoff P. [Indications and techniques of arthroscopic anterior and lateral acromioplasty]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 31:351-370. [PMID: 31363791 DOI: 10.1007/s00064-019-0620-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/12/2019] [Accepted: 04/22/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Arthroscopic anterior acromioplasty (AAAP) for treatment of symptomatic subacromial spur. Arthroscopic lateral acromioplasty (ALAP) to reduce a pathological critical shoulder angle (CSA) and prevent rotator cuff re-tear after reconstruction. INDICATIONS AAAP is indicated for acromial impingement due to an anterolateral acromial spur with or without bursa-sided rotator cuff lesion. ALAP is indicated concomitant to arthroscopic rotator cuff repair if the CSA is pathologically increased. RELATIVE CONTRAINDICATIONS Irreparable rotator cuff tear with acetabularization of the acromion due to anterosuperior escape of the humeral head or symptomatic os acromiale can contraindicate for AAAP. Dehiscence of the origin of the deltoid muscle or symptomatic os acromiale can contraindicate for ALAP. SURGICAL TECHNIQUE To preform AAAP, arthroscopic subacromial decompression is followed by anterolateral resection of an acromion spur or ossification of the coracoacromial ligament. To perform ALAP, arthroscopic subacromial decompression and reconstruction of a rotator cuff-tear is followed by reduction of a pathologically increased CSA by resection of the lateral edge of the acromion. POSTOPERATIVE MANAGEMENT After isolated AAAP, physiotherapy can be performed without restriction. After AAAP or ALAP combined with rotator cuff repair, immobilization in a brace is recommended. The use of pain medication should be standardized and adapted to individual pain levels.
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Affiliation(s)
- Kilian Rueckl
- Lehrstuhl für Orthopädie, König-Ludwig-Haus, Universität Würzburg, Brettreichstraße 11, 97074, Würzburg, Deutschland.
| | - Lukas Ernstbrunner
- Universitätsklinik Balgrist, Abteilung für Schulter- & Ellbogenchirurgie, Universität Zürich, Forchstrasse 340, 8008, Zürich, Schweiz
| | - Thomas Reichel
- Lehrstuhl für Orthopädie, König-Ludwig-Haus, Universität Würzburg, Brettreichstraße 11, 97074, Würzburg, Deutschland
| | - Samy Bouaicha
- Universitätsklinik Balgrist, Abteilung für Schulter- & Ellbogenchirurgie, Universität Zürich, Forchstrasse 340, 8008, Zürich, Schweiz
| | - Thomas Barthel
- Lehrstuhl für Orthopädie, König-Ludwig-Haus, Universität Würzburg, Brettreichstraße 11, 97074, Würzburg, Deutschland
| | - Maximilian Rudert
- Lehrstuhl für Orthopädie, König-Ludwig-Haus, Universität Würzburg, Brettreichstraße 11, 97074, Würzburg, Deutschland
| | - Piet Plumhoff
- Lehrstuhl für Orthopädie, König-Ludwig-Haus, Universität Würzburg, Brettreichstraße 11, 97074, Würzburg, Deutschland
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15
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Effects of Adding Interferential Therapy Electro-Massage to Usual Care after Surgery in Subacromial Pain Syndrome: A Randomized Clinical Trial. J Clin Med 2019; 8:jcm8020175. [PMID: 30717426 PMCID: PMC6406802 DOI: 10.3390/jcm8020175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 01/27/2019] [Accepted: 01/30/2019] [Indexed: 11/17/2022] Open
Abstract
Subacromial pain syndrome (SAPS) is a prevalent condition that results in loss of function. Surgery is indicated when pain and functional limitations persist after conservative measures, with scarce evidence about the most-appropriate post-operative approach. Interferential therapy (IFT), as a supplement to other interventions, has shown to relieve musculoskeletal pain. The study aim was to investigate the effects of adding IFT electro-massage to usual care after surgery in adults with SAPS. A randomized, single-blinded, controlled trial was carried out. Fifty-six adults with SAPS, who underwent acromioplasty in the previous 12 weeks, were equally distributed into an IFT electro-massage group or a control group. All participants underwent a two-week intervention (three times per week). The control group received usual care (thermotherapy, therapeutic exercise, manual therapy, and ultrasound). For participants in the IFT electro-massage group, a 15-min IFT electro-massage was added to usual care in every session. Shoulder pain intensity was assessed with a 100-mm visual analogue scale. Secondary measures included upper limb functionality (Constant-Murley score), and pain-free passive range of movement. A blinded evaluator collected outcomes at baseline and after the last treatment session. The ANOVA revealed a significant group effect, for those who received IFT electro-massage, for improvements in pain intensity, upper limb function, and shoulder flexion, abduction, internal and external rotation (all, p < 0.01). There were no between-group differences for shoulder extension (p = 0.531) and adduction (p = 0.340). Adding IFT electro-massage to usual care, including manual therapy and exercises, revealed greater positive effects on pain, upper limb function, and mobility in adults with SAPS after acromioplasty.
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16
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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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Lähdeoja T, Karjalainen T, Jokihaara J, Salamh P, Kavaja L, Agarwal A, Winters M, Buchbinder R, Guyatt G, Vandvik PO, Ardern CL. Subacromial decompression surgery for adults with shoulder pain: a systematic review with meta-analysis. Br J Sports Med 2019; 54:665-673. [PMID: 30647053 DOI: 10.1136/bjsports-2018-100486] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2018] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To determine the benefits and harms of subacromial decompression surgery in adult patients with subacromial pain syndrome lasting for more than 3 months. DESIGN Systematic review with meta-analysis. MAIN OUTCOME MEASURES Pain, physical function and health-related quality of life. DATA SOURCES Systematic searches for benefits and harms were conducted to 23 July 2018 in MEDLINE, Embase, PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature, Physiotherapy Evidence Database, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, Database of Abstracts of Reviews of Effects, and Health Technology Assessment. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials comparing subacromial decompression surgery for subacromial pain syndrome with any other treatment(s). For harms, we included prospective cohort studies. REVIEW METHODS Two reviewers independently determined eligibility, extracted the data and assessed the risk of bias of eligible studies. Thirty patients seeking primary or outpatient care for subacromial pain syndrome and a parallel guideline committee (BMJ Rapid Recommendations) provided input regarding systematic review design and interpretation. RESULTS There was high certainty evidence of no additional benefit of subacromial decompression surgery over placebo surgery in reducing pain at 1 year following surgery (mean difference [MD] -0.26, 95% CI -0.84 to 0.33, minimally important difference [MID] 1.5) or improving physical function at 1-2 years (MD 2.8, 95% CI -1.4 to 6.9, MID 8.3). There was moderate certainty evidence for no additional benefit of subacromial decompression surgery on health-related quality of life at 1 year (MD -0.03 points, 95% CI -0.11 to 0.06, MID 0.07). There was moderate certainty evidence for six serious harms per 1000 (95% CI 5 to 7) patients undergoing subacromial decompression. CONCLUSION Subacromial decompression surgery provided no important benefit compared with placebo surgery or exercise therapy, and probably carries a small risk of serious harms. SYSTEMATIC REVIEWREGISTRATION NUMBER CRD42018086862.
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Affiliation(s)
- Tuomas Lähdeoja
- Finnish Centre for Evidence-Based Orthopedics (FICEBO), University of Helsinki, Helsinki, Finland.,Department of Orthopaedics and Traumatology, HUS Helsinki University Hospital, Helsinki, Finland
| | - Teemu Karjalainen
- Finnish Centre for Evidence-Based Orthopedics (FICEBO), University of Helsinki, Helsinki, Finland.,Monash Department of Clinical Epidemiology, Cabrini Institute; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria, Australia
| | - Jarkko Jokihaara
- Finnish Centre for Evidence-Based Orthopedics (FICEBO), University of Helsinki, Helsinki, Finland.,Department of Hand Surgery, Tampere University Hospital, Tampere, Finland
| | - Paul Salamh
- College of Health Sciences, University of Indianapolis, Indianapolis, Indiana, USA
| | - Lauri Kavaja
- Medical Faculty, University of Helsinki, Helsinki, Finland.,Department of Surgery, South Karelia Central Hospital, Lappeenranta, Finland
| | - Arnav Agarwal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marinus Winters
- Research Unit for General Practice in Aalborg, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria, Australia
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Per Olav Vandvik
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway.,Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Clare L Ardern
- Division of Physiotherapy, Linköping University, Linköping, Sweden.,School of Allied Health, La Trobe University, Melbourne, Victoria, Australia
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Paavola M, Malmivaara A, Taimela S, Kanto K, Inkinen J, Kalske J, Sinisaari I, Savolainen V, Ranstam J, Järvinen TLN. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial. BMJ 2018; 362:k2860. [PMID: 30026230 PMCID: PMC6052435 DOI: 10.1136/bmj.k2860] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the efficacy of arthroscopic subacromial decompression (ASD) by comparing it with diagnostic arthroscopy, a placebo surgical intervention, and with a non-operative alternative, exercise therapy, in a more pragmatic setting. DESIGN Multicentre, three group, randomised, double blind, sham controlled trial. SETTING Orthopaedic departments at three public hospitals in Finland. PARTICIPANTS 210 patients with symptoms consistent with shoulder impingement syndrome, enrolled from 1 February 2005 with two year follow-up completed by 25 June 2015. INTERVENTIONS ASD, diagnostic arthroscopy (placebo control), and exercise therapy. MAIN OUTCOME MEASURES Shoulder pain at rest and on arm activity (visual analogue scale (VAS) from 0 to 100, with 0 denoting no pain), at 24 months. The threshold for minimal clinically important difference was set at 15. RESULTS In the primary intention to treat analysis (ASD versus diagnostic arthroscopy), no clinically relevant between group differences were seen in the two primary outcomes at 24 months (mean change for ASD 36.0 at rest and 55.4 on activity; for diagnostic arthroscopy 31.4 at rest and 47.5 on activity). The observed mean difference between groups (ASD minus diagnostic arthroscopy) in pain VAS were -4.6 (95% confidence interval -11.3 to 2.1) points (P=0.18) at rest and -9.0 (-18.1 to 0.2) points (P=0.054) on arm activity. No between group differences were seen between the ASD and diagnostic arthroscopy groups in the secondary outcomes or adverse events. In the secondary comparison (ASD versus exercise therapy), statistically significant differences were found in favour of ASD in the two primary outcomes at 24 months in both VAS at rest (-7.5, -14.0 to -1.0, points; P=0.023) and VAS on arm activity (-12.0, -20.9 to -3.2, points; P=0.008), but the mean differences between groups did not exceed the pre-specified minimal clinically important difference. Of note, this ASD versus exercise therapy comparison is not only confounded by lack of blinding but also likely to be biased in favour of ASD owing to the selective removal of patients with likely poor outcome from the ASD group, without comparable exclusions from the exercise therapy group. CONCLUSIONS In this controlled trial involving patients with a shoulder impingement syndrome, arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy at 24 months. TRIAL REGISTRATION Clinicaltrials.gov NCT00428870.
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Affiliation(s)
- Mika Paavola
- Department of Orthopedics and Traumatology, Helsinki University Hospital, Töölö hospital, Helsinki, Finland
| | - Antti Malmivaara
- National Institute for Health and Welfare, Centre for Health and Social Economics, Helsinki, Finland
| | - Simo Taimela
- Department of Orthopedics and Traumatology, Helsinki University Hospital, Töölö hospital, Helsinki, Finland
- Finnish Centre for Evidence-Based Orthopedics (FICEBO), Department of Orthopedics and Traumatology, University of Helsinki, Helsinki, Finland
| | - Kari Kanto
- Department of Orthopedics and Traumatology, Tampere University Hospital, TAYS Hatanpää, Tampere, Finland
| | - Jari Inkinen
- Fysios Finlayson, Physiotherapy Centre Kunnon Klinikka Oy, Tampere, Finland
| | - Juha Kalske
- Department of Orthopedics and Traumatology, Helsinki University Hospital, Jorvi Hospital, Espoo, Finland
| | | | | | - Jonas Ranstam
- Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Teppo L N Järvinen
- Department of Orthopedics and Traumatology, Helsinki University Hospital, Töölö hospital, Helsinki, Finland
- Finnish Centre for Evidence-Based Orthopedics (FICEBO), Department of Orthopedics and Traumatology, University of Helsinki, Helsinki, Finland
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Kolk A, Nelissen RGHH, Thomassen BJW, van Arkel ERA, Hund H, Wassenaar WG, de Witte PB, Henkus HE. Response to Hustedt et al regarding: "Does acromioplasty result in favorable clinical and radiologic outcomes in the management of chronic subacromial pain syndrome? A double-blinded randomized clinical trial with 9 to 14 years' follow-up". J Shoulder Elbow Surg 2018; 27:e84-e85. [PMID: 29307676 DOI: 10.1016/j.jse.2017.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 11/03/2017] [Indexed: 02/01/2023]
Affiliation(s)
- Arjen Kolk
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Bregje J W Thomassen
- Department of Orthopaedic Surgery and Trauma, Haaglanden Medical Center, The Hague, The Netherlands
| | - Ewoud R A van Arkel
- Department of Orthopaedic Surgery and Trauma, Haaglanden Medical Center, The Hague, The Netherlands
| | - Hajo Hund
- Department of Radiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Willem G Wassenaar
- Department of Radiology, Haaglanden Medical Center, The Hague, The Netherlands
| | | | - Hans-Erik Henkus
- Department of Orthopaedics, Haga Hospital, The Hague, The Netherlands
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Sonographic assessment of subacromial bursa distension during arm abduction: establishing a threshold value in the diagnosis of subacromial impingement syndrome. J Med Ultrason (2001) 2017; 45:287-294. [DOI: 10.1007/s10396-017-0839-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 09/29/2017] [Indexed: 02/07/2023]
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