Clinical study comparing acupuncture, physiotherapy, injection and oral anti-inflammatory therapy in shoulder-cuff lesions

Therapeutic Ultrasound for Chronic Pain Management in Joints: A Systematic Review

BACKGROUND

Treatments for joint pain and dysfunction focus on restoration of joint motion, improvement in pain and a return to the previous level of the patient's daily activity. Therapeutic ultrasound is a noninvasive modality widely utilized in the management of musculoskeletal disorders. The objective of this systematic review was to evaluate the effectiveness of therapeutic ultrasound in the management of patients with knee, shoulder and hip pain.

METHODS

Using PRISMA guidelines, a search of the PubMed, CENTRAL (The Cochrane Library), Web of Science and Scopus databases was performed to retrieve randomized controlled trials (RCTs) that evaluated therapeutic ultrasound (continuous and pulsed) in patients with chronic knee, shoulder and hip pain.

RESULTS

The search strategy identified 8 trials for knee, 7 trials for shoulder and 0 trials for hip that met the criteria for inclusion. All 8 trials showed improvement in knee pain, and of these studies 3 showed statistical significance improvement for therapeutic ultrasound versus the comparator. For shoulder pain, all 7 trials showed reduction in pain, but should be noted that 4 of studies demonstrated that therapeutic ultrasound is inferior to the comparator modality.

CONCLUSION

Therapeutic ultrasound is frequently used in the treatment of knee, shoulder and hip pain and is often combined with other physiotherapeutic modalities. The literature on knee arthritis is most robust, with some evidence supporting therapeutic ultrasound, though the delivery method of ultrasound (pulsed vs continuous) is controversial. As a monotherapy, ultrasound treatment may not have a significant impact on functional improvement but can be a reasonable adjunct to consider with other common modalities. In all three pain syndromes, especially for hip pain, further trials are needed to define the true effect of low-intensity ultrasound therapy knee, shoulder and hip pain. No conclusive recommendations may be made for optimal settings or session duration.

Frozen Shoulder: A Comparison of Western and Traditional Chinese Approaches and a Clinical Study of Its Acupuncture Treatment

A pilot study using acupuncture in the treatment of 31 patients with frozen shoulder showed marked improvement in 24 and improvement in 6. Patients with idiopathic or arthritic frozen shoulder responded better than those with post-traumatic aetiology. There was no relationship between response to acupuncture and age.

Although this study involved no control group, the high level of improvement together with the author's clinical experience suggests that acupuncture should be considered an effective option in the treatment of frozen shoulder; the more so since conventional medical therapy has a low expectation of benefit. Aetiology pathology and clinical management are described in both Western medical and traditional Chinese terms and details of acupuncture treatment methods are given.

Comparison of Subacromial Ketorolac Injection versus Corticosteroid Injection in the Treatment of Shoulder Impingement Syndrome

Objective:

Subacromial impingement syndrome is the most common cause of shoulder pain and restriction in range of motion in the world. The aim of this study was to compare the efficacy of subacromial injection of ketorolac with the injection of corticosteroid for the treatment of subacromial impingement syndrome.

Methods:

A total of forty patients were randomly allocated into two groups. Group A received 40 mg of methylprednisolone and Group B received 60 mg of ketorolac as a subacromial injection along with lidocaine. Each patient was evaluated in terms of visual analog scale (VAS) for evaluating pain and Constant's score for function evaluation (pain, activity level, and range of motion with standard goniometry). The patients were re-examined 1 and 3 months after intervention. All the patients educated for simple home exercise.

Findings:

At 1 and 3 months of follow-up, both treatment arms resulted in an increased range of motion and decreased pain. The difference between the groups was not statistically significant (P > 0.05). In ketorolac group, mean pre- and post-treatment (at 12 weeks) VAS scores were 8.6 (range, 3–9) and 4.5 (range 2–4), respectively. In steroid group, mean pre- and post-treatment (at 12 weeks) VAS scores were 8.3 (range, 3–10) and 3.9 (range, 0–7), respectively. The difference was statistically significant within groups at baseline and 1 (P < 0.001) and 3 (P < 0.001) months after the injection.

Conclusion:

Subacromial injection of ketorolac has an equivalent outcome to subacromial injection of corticosteroid. The use of ketorolac injections can substantially decrease the pain and increase the range of motion of the shoulder and could be a reasonable alternative in case of corticosteroid contraindications.

A Review of Systematic Reviews of the Effectiveness of Conservative Interventions for Rotator Cuff Tendinopathy

Background

Rotator cuff tendinopathy is common and a wide range of conservative interventions are currently used to treat this problem. The purpose of this review is to systematically review the systematic reviews that evaluate the effectiveness of conservative interventions for rotator cuff tendinopathy.

Methods

An electronic search of PEDro, MEDLINE and the Cochrane Library was undertaken and supplemented by hand and citation searching. The AMSTAR checklist was adopted for quality appraisal and a narrative synthesis was undertaken.

Results

Twenty-six systematic reviews were retrieved. Methodological quality was variable. Exercise and multimodal physiotherapy appear to confer superior outcomes over no treatment or placebo, although the clinical significance of these results remains unclear. Surgery does not confer an additional benefit over exercise alone or multimodal physiotherapy. Combining manual therapy with exercise is not currently supported, neither is the use of corticosteroid injections or acupuncture. Other commonly prescribed interventions lack evidence of effectiveness.

Conclusions

Exercise and multimodal physiotherapy might be effective interventions for rotator cuff tendinopathy, although the clinical significance of this effect is unclear. This interpretation is drawn from systematic reviews comprising mainly small randomized controlled trials that frequently measure outcome in a heterogeneous manner, limiting the strength of any conclusions.

Protocol: Testing the Relevance of Acupuncture Theory in the Treatment of Myofascial Pain in the Upper Trapezius Muscle

A protocol for a prospective single-blind parallel four-arm randomized placebo-controlled trial with repeated measures was designed to test the effects of various acupuncture methods compared with sham. Eighty self-selected participants with myofascial pain in the upper trapezius muscle were randomized into four groups. Group 1 received acupuncture to a myofascial trigger point (MTrP) in the upper trapezius. Group 2 received acupuncture to the MTrP in addition to relevant distal points. Group 3 received acupuncture to the relevant distal points only. Group 4 received a sham treatment to both the MTrP and distal points using a deactivated acupuncture laser device. Treatment was applied four times within 2 weeks with outcomes measured throughout the trial and at 2 weeks and 4 weeks posttreatment. Outcome measurements were a 100-mm visual analog pain scale, SF-36, pressure pain threshold, Neck Disability Index, the Upper Extremity Functional Index, lateral flexion in the neck, McGill Pain Questionnaire, Massachusetts General Hospital Acupuncture Sensation Scale, Working Alliance Inventory (short form), and the Credibility Expectance Questionnaire. Two-way analysis of variance (ANOVA) with repeated measures were used to assess the differences between groups.

Efficiency of therapeutic ultrasound on pain, disability, anxiety, depression, sleep and quality of life in patients with subacromial impingement syndrome: A randomized controlled study

BACKGROUND

Subacromial impingement syndrome (SIS) is characterized by pain and disability of shoulder. Various treatment methods have been used for SIS.

OBJECTIVES

The aim of our study was to evaluate efficacy of therapeutic ultrasound (US) on pain, disability, anxiety, depression, sleep quality and quality of life in patients with SIS.

METHODS

Patients with SIS were randomly divided into two groups, including the group 1 (continuous US group; 3 MHz, 1.5 W/cm2, n = 26) and group 2 (sham US group, n = 24). Additionally, transcutaneous electrical nerve stimulation (TENS) + exercise program were added in both groups. Pain and disability of the shoulder were assessed by the Shoulder Pain and Disability Index (SPADI), while anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale. The Pittsburgh Sleep Quality Index (PSQI) was used to evaluate sleep quality. Quality of life was evalutaed by the Nottingham Health Profile (NHP). Patients were evaluated at baseline and after end of three weeks.

RESULTS

Both groups had significantly improvements in terms of SPADI-pain, SPADI-disability, SPADI-total, NHP-pain and NHP-sleep scores after the three weeks interventions. There were significantly improvements in the Group 1 in terms of PSQI-total, and NHP-physical activity. Group 2 had significantly improvements in terms of anxiety-HADS, depression-HADS and NHP-emotional reaction scores. In the inter-group comparison, there were no significantly differences in the change scores were observed in any domains of SPADI scores, anxiety, depression and sleep scores, or any NHP scores.

CONCLUSIONS

Our study showed that US does not have any benefits on SIS. TENS + exercise program are not effective on anxiety, depression and fatigue, however TENS +$ exercise program are effective on pain, disability and sleep disturbance in patients with SIS.

Electrotherapy modalities for rotator cuff disease

BACKGROUND

Management of rotator cuff disease may include use of electrotherapy modalities (also known as electrophysical agents), which aim to reduce pain and improve function via an increase in energy (electrical, sound, light, or thermal) into the body. Examples include therapeutic ultrasound, low-level laser therapy (LLLT), transcutaneous electrical nerve stimulation (TENS), and pulsed electromagnetic field therapy (PEMF). These modalities are usually delivered as components of a physical therapy intervention. This review is one of a series of reviews that form an update of the Cochrane review, 'Physiotherapy interventions for shoulder pain'.

OBJECTIVES

To synthesise available evidence regarding the benefits and harms of electrotherapy modalities for the treatment of people with rotator cuff disease.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE (January 1966 to March 2015), Ovid EMBASE (January 1980 to March 2015), CINAHL Plus (EBSCOhost, January 1937 to March 2015), ClinicalTrials.gov and the WHO ICTRP clinical trials registries up to March 2015, unrestricted by language, and reviewed the reference lists of review articles and retrieved trials, to identify potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-randomised trials, including adults with rotator cuff disease (e.g. subacromial impingement syndrome, rotator cuff tendinitis, calcific tendinitis), and comparing any electrotherapy modality with placebo, no intervention, a different electrotherapy modality or any other intervention (e.g. glucocorticoid injection). Trials investigating whether electrotherapy modalities were more effective than placebo or no treatment, or were an effective addition to another physical therapy intervention (e.g. manual therapy or exercise) were the main comparisons of interest. Main outcomes of interest were overall pain, function, pain on motion, patient-reported global assessment of treatment success, quality of life and the number of participants experiencing adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted the data, performed a risk of bias assessment and assessed the quality of the body of evidence for the main outcomes using the GRADE approach.

MAIN RESULTS

We included 47 trials (2388 participants). Most trials (n = 43) included participants with rotator cuff disease without calcification (four trials included people with calcific tendinitis). Sixteen (34%) trials investigated the effect of an electrotherapy modality delivered in isolation. Only 23% were rated at low risk of allocation bias, and 49% were rated at low risk of both performance and detection bias (for self-reported outcomes). The trials were heterogeneous in terms of population, intervention and comparator, so none of the data could be combined in a meta-analysis.In one trial (61 participants; low quality evidence), pulsed therapeutic ultrasound (three to five times a week for six weeks) was compared with placebo (inactive ultrasound therapy) for calcific tendinitis. At six weeks, the mean reduction in overall pain with placebo was -6.3 points on a 52-point scale, and -14.9 points with ultrasound (MD -8.60 points, 95% CI -13.48 to -3.72 points; absolute risk difference 17%, 7% to 26% more). Mean improvement in function with placebo was 3.7 points on a 100-point scale, and 17.8 points with ultrasound (mean difference (MD) 14.10 points, 95% confidence interval (CI) 5.39 to 22.81 points; absolute risk difference 14%, 5% to 23% more). Ninety-one per cent (29/32) of participants reported treatment success with ultrasound compared with 52% (15/29) of participants receiving placebo (risk ratio (RR) 1.75, 95% CI 1.21 to 2.53; absolute risk difference 39%, 18% to 60% more). Mean improvement in quality of life with placebo was 0.40 points on a 10-point scale, and 2.60 points with ultrasound (MD 2.20 points, 95% CI 0.91 points to 3.49 points; absolute risk difference 22%, 9% to 35% more). Between-group differences were not important at nine months. No participant reported adverse events.Therapeutic ultrasound produced no clinically important additional benefits when combined with other physical therapy interventions (eight clinically heterogeneous trials, low quality evidence). We are uncertain whether there are differences in patient-important outcomes between ultrasound and other active interventions (manual therapy, acupuncture, glucocorticoid injection, glucocorticoid injection plus oral tolmetin sodium, or exercise) because the quality of evidence is very low. Two placebo-controlled trials reported results favouring LLLT up to three weeks (low quality evidence), however combining LLLT with other physical therapy interventions produced few additional benefits (10 clinically heterogeneous trials, low quality evidence). We are uncertain whether transcutaneous electrical nerve stimulation (TENS) is more or less effective than glucocorticoid injection with respect to pain, function, global treatment success and active range of motion because of the very low quality evidence from a single trial. In other single, small trials, no clinically important benefits of pulsed electromagnetic field therapy (PEMF), microcurrent electrical stimulation (MENS), acetic acid iontophoresis and microwave diathermy were observed (low or very low quality evidence).No adverse events of therapeutic ultrasound, LLLT, TENS or microwave diathermy were reported by any participants. Adverse events were not measured in any trials investigating the effects of PEMF, MENS or acetic acid iontophoresis.

AUTHORS' CONCLUSIONS

Based on low quality evidence, therapeutic ultrasound may have short-term benefits over placebo in people with calcific tendinitis, and LLLT may have short-term benefits over placebo in people with rotator cuff disease. Further high quality placebo-controlled trials are needed to confirm these results. In contrast, based on low quality evidence, PEMF may not provide clinically relevant benefits over placebo, and therapeutic ultrasound, LLLT and PEMF may not provide additional benefits when combined with other physical therapy interventions. We are uncertain whether TENS is superior to placebo, and whether any electrotherapy modality provides benefits over other active interventions (e.g. glucocorticoid injection) because of the very low quality of the evidence. Practitioners should communicate the uncertainty of these effects and consider other approaches or combinations of treatment. Further trials of electrotherapy modalities for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.

Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association

Treatment of "subacromial impingement syndrome" of the shoulder has changed drastically in the past decade. The anatomical explanation as "impingement" of the rotator cuff is not sufficient to cover the pathology. "Subacromial pain syndrome", SAPS, describes the condition better. A working group formed from a number of Dutch specialist societies, joined by the Dutch Orthopedic Association, has produced a guideline based on the available scientific evidence. This resulted in a new outlook for the treatment of subacromial pain syndrome. The important conclusions and advice from this work are as follows: (1) The diagnosis SAPS can only be made using a combination of clinical tests. (2) SAPS should preferably be treated non-operatively. (3) Acute pain should be treated with analgetics if necessary. (4) Subacromial injection with corticosteroids is indicated for persistent or recurrent symptoms. (5) Diagnostic imaging is useful after 6 weeks of symptoms. Ultrasound examination is the recommended imaging, to exclude a rotator cuff rupture. (6) Occupational interventions are useful when complaints persist for longer than 6 weeks. (7) Exercise therapy should be specific and should be of low intensity and high frequency, combining eccentric training, attention to relaxation and posture, and treatment of myofascial trigger points (including stretching of the muscles) may be considered. (8) Strict immobilization and mobilization techniques are not recommended. (9) Tendinosis calcarea can be treated by shockwave (ESWT) or needling under ultrasound guidance (barbotage). (10) Rehabilitation in a specialized unit can be considered in chronic, treatment resistant SAPS, with pain perpetuating behavior. (11) There is no convincing evidence that surgical treatment for SAPS is more effective than conservature management. (12) There is no indication for the surgical treatment of asymptomatic rotator cuff tears.

Low-level laser and local corticosteroid injection in the treatment of subacromial impingement syndrome: a controlled clinical trial

Objective:

To investigate the effectiveness of low-level laser treatment and local corticosteroid injection in patients with subacromial impingement syndrome.

Design:

Controlled clinical trial.

Setting:

Physical Medicine and Rehabilitation outpatient clinic.

Subjects:

One hundred thirty-five patients with subacromial impingement syndrome.

Intervention:

The patients were allocated to three groups: local corticosteroid injection (group I); sham laser treatment (group II); and low-level laser treatment (group III). Low-level laser treatment was performed three times per week for a total of nine sessions. Local corticosteroid injections were administered twice, with an interval of 10 days between each. The patients were assessed at pre-treatment, post-treatment and three and six months after the first visit.

Main measures:

The primary outcome of the study was pain intensity (visual analog scale) during activity and at rest. The secondary outcomes were, shoulder functional status and quality of life measured by the University of California at Los Angeles rating score (UCLA) and Nottingham Health Profile (NHP) scale respectively.

Results:

Significant differences were observed between groups I and II and between groups II and III regarding pain during activity and at rest scores at all of the visits ( p<0.05). Nevertheless, significant improvement was observed between groups I and III regarding pain during activity only at post-treatment ( p=0.013). The UCLA scores were significantly changed in all three study groups at all of the visits ( p<0.05).

Conclusion:

The effectiveness of low-level laser treatment was similar to that of local corticosteroid injection in patients with subacromial impingement syndrome. We concluded that both low-level laser treatment and corticosteroid injection were more effective than sham laser treatment.

Subacromial impingement syndrome--effectiveness of physiotherapy and manual therapy

BACKGROUND

The subacromial impingement syndrome (SIS) includes the rotator cuff syndrome, tendonitis and bursitis of the shoulder. Treatment includes surgical and non-surgical modalities. Non-surgical treatment is used to reduce pain, to decrease the subacromial inflammation, to heal the compromised rotator cuff and to restore satisfactory function of the shoulder. To select the most appropriate non-surgical intervention and to identify gaps in scientific knowledge, we explored the effectiveness of the interventions used, concentrating on the effectiveness of physiotherapy and manual therapy.

METHODS

The Cochrane Library, PubMed, EMBASE, PEDro and CINAHL were searched for relevant systematic reviews and randomised clinical trials (RCTs). Two reviewers independently extracted data and assessed the methodological quality. A best-evidence synthesis was used to summarise the results.

RESULTS

Two reviews and 10 RCTs were included. One RCT studied manual therapy as an add-on therapy to self-training. All other studies studied the effect of physiotherapy: effectiveness of exercise therapy, mobilisation as an add-on therapy to exercises, ultrasound, laser and pulsed electromagnetic field. Moderate evidence was found for the effectiveness of hyperthermia compared to exercise therapy or ultrasound in the short term. Hyperthermia and exercise therapy were more effective in comparison to controls or placebo in the short term (moderate evidence). For the effectiveness of hyperthermia, no midterm or long-term results were studied. In the midterm, exercise therapy gave the best results (moderate evidence) compared to placebo or controls. For other interventions, conflicting, limited or no evidence was found.

CONCLUSIONS

Some physiotherapeutic treatments seem to be promising (moderate evidence) to treat SIS, but more research is needed before firm conclusions can be drawn.

Subacromial impingement syndrome: effectiveness of pharmaceutical interventions-nonsteroidal anti-inflammatory drugs, corticosteroid, or other injections: a systematic review

OBJECTIVE

To present an evidence-based overview of the effectiveness of pharmaceutical interventions, including nonsteroidal anti-inflammatory drugs, corticosteroid injections, and other injections, used to treat the subacromial impingement syndrome (SIS). An overview can help physicians select the most appropriate pharmaceutical intervention, and it can identify gaps in scientific knowledge.

DATA SOURCES

The Cochrane Library, PubMed, Embase, PEDro, and CINAHL databases.

STUDY SELECTION

Two reviewers independently selected relevant reviews and randomized clinical trials.

DATA EXTRACTION

Two reviewers independently extracted the data and assessed the methodologic quality.

DATA SYNTHESIS

A best evidence synthesis was used to summarize the results. Three reviews and 5 randomized clinical trials were included. Although we found limited evidence for effectiveness in favor of 2 sessions with corticosteroid injections versus 1 session, for the effectiveness of corticosteroid injections versus placebo, nonsteroidal anti-inflammatory drugs, or acupuncture, only conflicting and no evidence for effectiveness was found. Moderate evidence was found in favor of immediate release oral ibuprofen compared with sustained-released ibuprofen in the short-term. Also, moderate evidence for effectiveness was found in favor of glyceryltrinitrate patches versus placebo patches in the short-term and mid term. Furthermore, injections with disodium ethylene diamine tetraacetic acid plus ultrasound with ethylene diamine tetraacetic acid gel were more effective (moderate evidence) than was placebo treatment in the short- and long-term.

CONCLUSIONS

This article presents an overview of the effectiveness of pharmaceutical interventions for SIS. Some treatments seem to be promising (moderate evidence) to treat SIS, but more research is needed before firm conclusions can be drawn.

Acupuncture in the treatment of rheumatic diseases

Acupuncture has been used for millennia in traditional Chinese medicine as a technique believed to restore the balance of energy in the body caused by disease through the use of needles inserted into specific points or energy channels. This energy is called the de qi. The use of acupuncture for the treatment of pain in musculoskeletal disorders is increasing. Some patients seek alternative therapies because of lack of improvement with conventional treatments. The potential physiological effects of acupuncture on pain relief have been attributed to biochemical processes, such as the release of endorphins into the limbic structures, subcortical areas and brain stem, mechanisms that are also present in placebo-induced analgesia. In addition, pain relief with acupuncture is also associated with patient expectations, beliefs, and interactions with their acupuncturists. In this review, we summarize the latest evidence on the treatment of musculoskeletal conditions including rheumatoid arthritis, fibromyalgia, neck pain, shoulder pain, low back pain, and knee pain with traditional Chinese acupuncture (TCA), electroacupuncture (EA), and the use of moxibustion. Acupuncture is relatively safe, but there are still reports of serious and fatal side effects that must be taken into account when recommending this therapy. Many of the latest trials assessing the benefits of acupuncture in rheumatic diseases found that acupuncture was not better than sham acupuncture, implying that the analgesic effects observed are related to a strong placebo response. While the literature on this topic is extensive, many of the studies lack methodological rigor, and additional large, well-controlled, high quality trials are still needed to determine if acupuncture might be useful in the treatment of chronic rheumatic diseases.

Acupuncture for chronic pain: individual patient data meta-analysis

BACKGROUND

Although acupuncture is widely used for chronic pain, there remains considerable controversy as to its value. We aimed to determine the effect size of acupuncture for 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain.

METHODS

We conducted a systematic review to identify randomized controlled trials (RCTs) of acupuncture for chronic pain in which allocation concealment was determined unambiguously to be adequate. Individual patient data meta-analyses were conducted using data from 29 of 31 eligible RCTs, with a total of 17 922 patients analyzed.

RESULTS

In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and no-acupuncture control for each pain condition (P < .001 for all comparisons). After exclusion of an outlying set of RCTs that strongly favored acupuncture, the effect sizes were similar across pain conditions. Patients receiving acupuncture had less pain, with scores that were 0.23 (95% CI, 0.13-0.33), 0.16 (95% CI, 0.07-0.25), and 0.15 (95% CI, 0.07-0.24) SDs lower than sham controls for back and neck pain, osteoarthritis, and chronic headache, respectively; the effect sizes in comparison to no-acupuncture controls were 0.55 (95% CI, 0.51-0.58), 0.57 (95% CI, 0.50-0.64), and 0.42 (95% CI, 0.37-0.46) SDs. These results were robust to a variety of sensitivity analyses, including those related to publication bias.

CONCLUSIONS

Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture.

The effectiveness of injections of hyaluronic acid or corticosteroid in patients with subacromial impingement

A total of 159 patients (84 women and 75 men, mean age of 53 (20 to 87)) with subacromial impingement were randomised to treatment with subacromial injections using lidocaine with one of hyaluronic acid (51 patients), corticosteroid (53 patients) or placebo (55 patients). Patients were followed up for 26 weeks. The primary outcome was pain on a visual analogue score (VAS), and secondary outcomes included the Constant Murley score, shoulder pain score, functional mobility score, shoulder disability questionnaire and pain-specific disability score. The different outcome measures showed similar results. After three, six and 12 weeks corticosteroid injections were superior to hyaluronic acid injections and only at six weeks significantly better than placebo injections. The mean short-term reduction in pain on the VAS score at 12 weeks was 7% (sd 2.7; 97.5% confidence interval (CI) 0.207 to 1.55; p = 0.084) in the hyaluronic acid group, 28% (sd 2.8; 97.5% CI 1.86 to 3.65; p < 0.001) in the corticosteroid group and 23% (sd 3.23; 97.5% CI 1.25 to 3.26; p < 0.001) in the placebo group. At 26 weeks there was a reduction in pain in 63% (32 of 51) of patients in the hyaluronic acid group, 72% (38 of 53) of those in the corticosteroid group and 69% (38 of 55) of those in the placebo group.

We were not able to show a convincing benefit from hyaluronic acid injections compared with corticosteroid or placebo injections. Corticosteroid injections produced a significant reduction in pain in the short term (three to 12 weeks), but in the long term the placebo injection produced the best results.

Positive outcomes with intra-articular glenohumeral injections are independent of accuracy

BACKGROUND

Shoulder pain is a common, costly, and recalcitrant affliction. One treatment for shoulder pain is intra-articular injection of corticosteroid. Clinical opinion is that injection guided by palpation is accurate and effective, and there is some evidence to support a positive effect of injection on pain. However, great controversy exists as to the accuracy of injection by palpation, whether or not accuracy is important, and what the effect is of accuracy on pain.

METHODS

We used a blinded, longitudinal observational design of effectiveness in an effort to determine the accuracy of intra-articular injections and the effect of that accuracy on pain and functional outcomes in patients with various shoulder pathologies.

RESULTS

Injection accuracy data were captured on 103 patients. Of the 103 blinded injections, 54 received injections that were identified by fluoroscopy as "in" the capsule, whereas 49 were identified as "outside" the capsule; an accuracy rate of 52.4%. In the 4-week follow up, regardless of group assignment or accuracy of the injection, patients improved significantly (P < .01) from pre- to post-injection. Improvement was typically over by 2.5 points in the Numeric Pain Rating Scale (NPRS) categories, over 8 points on the Short-Form McGill Pain Questionnaire (SFMPQ), and over by 13 points on the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH).

DISCUSSION

Our accuracy rate was within the range reported in the literature. Improvements in all subjects with regard to pain and self-reported function occurred even in light of a wide variance in subject duration of symptoms, multiple injectors with varied training, a blinded approach to injection, and multiple injection approaches.

CONCLUSIONS

The accuracy of the injection does not appear to depend on the experience of the physician and may be irrelevant in treating shoulder pain of multiple origins.

German Randomized Acupuncture Trial for chronic shoulder pain (GRASP) - a pragmatic, controlled, patient-blinded, multi-centre trial in an outpatient care environment

The German Randomized Acupuncture Trial for chronic shoulder pain (GRASP) comprised 424 outpatients with chronic shoulder pain (CSP) > or =6 weeks and an average pain score of VAS > or =50 mm, who were randomly assigned to receive Chinese acupuncture (verum), sham acupuncture (sham) or conventional conservative orthopaedic treatment (COT). The patients were blinded to the type of acupuncture and treated by 31 office-based orthopaedists trained in acupuncture; all received 15 treatments over 6 weeks. The 50% responder rate for pain was measured on a VAS 3 months after the end of treatment (primary endpoint) and directly after the end of the treatment (secondary endpoint).

RESULTS

In the ITT (n=424) analysis, percentages of responders for the primary endpoint were verum 65% (95% CI 56-74%) (n=100), sham 24% (95% CI 9-39%) (n=32), and COT 37% (95% CI 24-50%) (n=50); secondary endpoint: verum 68% (95% CI 58-77%) (n=92), sham 40% (95% CI 27-53%) (n=53), and COT 28% (95% CI 14-42%) (n=38). The results are significant for verum over sham and verum over COT (p<0.01) for both the primary and secondary endpoints. The PPP analysis of the primary (n=308) and secondary endpoints (n=360) yields similar responder results for verum over sham and verum over COT (p<0.01). Descriptive statistics showed greater improvement of shoulder mobility (abduction and arm-above-head test) for the verum group versus the control group immediately after treatment and after 3 months. The trial indicates that Chinese acupuncture is an effective alternative to conventional orthopaedic treatment for CSP.

A double-blind randomised controlled study comparing subacromial injection of tenoxicam or methylprednisolone in patients with subacromial impingement

We have carried out a prospective double-blind randomised controlled trial to compare the efficacy of a single subacromial injection of the non-steroidal anti-inflammatory drug, tenoxicam, with a single injection of methylprednisolone in patients with subacromial impingement. A total of 58 patients were randomly allocated into two groups. Group A received 40 mg of methylprednisolone and group B 20 mg of tenoxicam as a subacromial injection along with lignocaine. The Constant-Murley shoulder score was used as the primary outcome measure and the Disability of Arm, Shoulder and Hand (DASH) and the Oxford Shoulder Score (OSS) as secondary measures. Six weeks after injection the improvement in the Constant-Murley score was significantly greater in the methylprednisolone group (p = 0.003) than in the tenoxicam group. The improvement in the DASH score was greater in the steroid group and the difference was statistically significant and consistent two (p < 0.01), four (p < 0.01) and six weeks (p < 0.020) after the injection. The improvement in the OSS was consistently greater in the steroid group than in the tenoxicam group. Although the difference was statistically significant at two (p < 0.001) and four (p = 0.003) weeks after the injection, it was not at six weeks (p = 0.055). Subacromial injection of tenoxicam does not offer an equivalent outcome to subacromial injection of corticosteroid at six weeks. Corticosteroid is significantly better than tenoxicam for improving shoulder function in tendonitis of the rotator cuff after six weeks.

Short-term effects of high-intensity laser therapy versus ultrasound therapy in the treatment of people with subacromial impingement syndrome: a randomized clinical trial

BACKGROUND

Subacromial impingement syndrome (SAIS) is a painful condition resulting from the entrapment of anatomical structures between the anteroinferior corner of the acromion and the greater tuberosity of the humerus.

OBJECTIVE

The aim of this study was to evaluate the short-term effectiveness of high-intensity laser therapy (HILT) versus ultrasound (US) therapy in the treatment of SAIS.

DESIGN

The study was designed as a randomized clinical trial.

SETTING

The study was conducted in a university hospital.

PATIENTS

Seventy patients with SAIS were randomly assigned to a HILT group or a US therapy group.

INTERVENTION

Study participants received 10 treatment sessions of HILT or US therapy over a period of 2 consecutive weeks.

MEASUREMENTS

Outcome measures were the Constant-Murley Scale (CMS), a visual analog scale (VAS), and the Simple Shoulder Test (SST).

RESULTS

For the 70 study participants (42 women and 28 men; mean [SD] age=54.1 years [9.0]; mean [SD] VAS score at baseline=6.4 [1.7]), there were no between-group differences at baseline in VAS, CMS, and SST scores. At the end of the 2-week intervention, participants in the HILT group showed a significantly greater decrease in pain than participants in the US therapy group. Statistically significant differences in change in pain, articular movement, functionality, and muscle strength (force-generating capacity) (VAS, CMS, and SST scores) were observed after 10 treatment sessions from the baseline for participants in the HILT group compared with participants in the US therapy group. In particular, only the difference in change of VAS score between groups (1.65 points) surpassed the accepted minimal clinically important difference for this tool.

LIMITATIONS

This study was limited by sample size, lack of a control or placebo group, and follow-up period.

CONCLUSIONS

Participants diagnosed with SAIS showed greater reduction in pain and improvement in articular movement functionality and muscle strength of the affected shoulder after 10 treatment sessions of HILT than did participants receiving US therapy over a period of 2 consecutive weeks.

WITHDRAWN: Interventions for tears of the rotator cuff in adults

BACKGROUND

Tears of the rotator cuff tendons, which surround the joints of the shoulder, are one of the most common causes of pain and disability in the upper extremity.

OBJECTIVES

To review the efficacy and safety of common interventions for tears of the rotator cuff in adults.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised trail register (July 2002), the Cochrane Controlled Trials Register (The Cochrane Library issue 2, 2002), MEDLINE (1966 to December 2001), EMBASE (1974 to December 2001), Biological Abstracts (1980 to December 2001), LILACS (1982 to December 2001), CINAHL (November 1982 to December 2001), Science Citation Index and reference lists of articles. We also contacted authors and handsearched conference proceedings focusing on shoulder conditions.

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials involving tears of the rotator cuff were the focus of this review. All trials involving conservative interventions or surgery were included (non-steroidal anti-inflammatory drugs, intra-articular or subacromial glucocorticosteroid injection, oral glucocorticosteroid treatment, physiotherapy, and open or arthroscopic surgery).

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed suitability for inclusion, methodological quality and extracted data. Dichotomous data were presented as relative risks (RR) and 95% confidence intervals (CI), using the fixed effects model.

MAIN RESULTS

Eight trials involving 455 people were included and 393 patients analysed. Trials were grouped in eight categories of conservative or surgical treatment. The median quality score of all trials combined was 16 out of a possible 24 points, with a range of 12-18. In general, included trials differed on diagnostic criteria for rotator cuff tear, there was no uniformity in reported outcome measures, and data which could be summarised were rarely reported. Only results from two studies comparing open repair to arthroscopic debridement could be pooled. There is weak evidence for the superiority of open repair of rotator cuff tears compared with arthroscopic debridement.

AUTHORS' CONCLUSIONS

There is little evidence to support or refute the efficacy of common interventions for tears of rotator cuff in adults. As well as the need for further well designed clinical trials, uniform methods of defining interventions for rotator cuff tears and validated outcome measures are also essential.

Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials

Objectives:

To assess the efficacy and safety of steroid injections for patients with tendonitis of the shoulder or elbow.

Methods:

A systematic review of the literature using PubMed, EMBASE, the Cochrane library and manual searches was performed until April 2008. All randomised controlled trials (RCTs) reporting the efficacy on pain or functional disability, and/or the safety of steroid injections, versus placebo, non-steroidal anti-inflammatory drugs (NSAIDs) or physiotherapy in patients with tendonitis were selected. Pooled effect size (ES) was calculated by meta-analysis using the Mantel–Haenszel method.

Results:

In all, 20 RCTs were analysed (744 patients treated by injections and 987 patients treated by controls; 618 shoulders and 1113 elbows). The pooled analysis indicated only short-term effectiveness of steroids versus the pooled controls for pain and function (eg, pain at week 1–3 ES = 1.18 (95% CI 0.27 to 2.09), pain at week 4–8 ES = 1.30 (95% CI 0.55 to 2.04), pain at week 12–24 ES = −0.38 (95% CI −0.85 to 0.08) and pain at week 48 ES = 0.07 (95% CI −0.60 to 0.75)). Sensitivity analyses indicated similar results whatever the localisation, type of steroid and type of comparator except for NSAIDs: steroid injections were not significantly better than NSAIDs in the short-term. Steroid injections appeared more effective than pooled other treatments in acute or subacute tendonitis. The main side effects were transient pain after injection (10.7% of corticosteroid injections) and skin modification (4.0%).

Conclusions:

Steroid injections are well tolerated and more effective for tendonitis in the short-term than pooled other treatments, though similar to NSAIDs. No long-term benefit was shown.

Injection therapies for soft-tissue lesions

Local injection therapies, used in the management of a variety of musculoskeletal pain syndromes, include the local infiltration of substances such as corticosteroid, anaesthetic, sclerosants and botulinum toxin, as well as dry needling alone and neural blockade. In this chapter, a number of injection therapies for soft-tissue-mediated pain are described. The reasoning for their use, potential mechanisms of action and unwanted effects are discussed. The literature relating to their effects is critically reviewed. Practical suggestions for their utilisation in the management of soft-tissue conditions are given and proposals are made for future research in this important area.

WITHDRAWN: Interventions for shoulder pain

BACKGROUND

Shoulder pain is a common problem and although there are many accepted standard forms of conservative therapy for shoulder disorders including non-steroidal anti-inflammatory drugs, glucocorticosteroid injections, oral glucocorticosteroid medication, manipulation under anaesthesia, physical therapy, hydrodilatation (distension arthrography) and surgery, evidence of their efficacy is not well established.

OBJECTIVES

To review the efficacy of common interventions for shoulder pain.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Group trials register, Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, and Science Citation Index) up to May 1998, and hand searched major textbooks, bibliographies of relevant literature, the fugitive literature, and the subject indices of relevant journals including: American College of Rheumatology;British College of Rheumatologists; the Biennial Conference of the Manipulative Physiotherapy Association of Australia;International Federation of Manual Therapists conference proceedings; British Orthopaedic Association;and American Orthopaedic Association.

SELECTION CRITERIA

Each identified study was assessed for possible inclusion by two independent reviewers based on the blinded methods sections. The determinants for inclusion were that the trial include an intervention of interest (non-steroidal anti-inflammatory drugs, intra-articular or subacromial glucocorticosteroid injection, oral glucocorticosteroid treatment, physiotherapy, manipulation under anaesthesia, hydrodilatation, or surgery); that treatment allocation was randomized; and that the outcome assessment was blinded.

DATA COLLECTION AND ANALYSIS

Methodological quality was assessed by two independent, blinded reviewers. Data relating to selection criteria, outcome measurement and treatment effect was extracted from the blinded trials. Range of motion scores were entered as degrees of restriction to movement, and all pain and overall effect scores were transformed to 100 point scales. For continuous outcome measures, where standard deviation was not reported it was either calculated from the raw data or converted from standard error of the mean. If neither of these were reported, authors were contacted in an effort to obtain the missing values. Effect sizes were calculated and combined in a pooled analysis if study population, endpoint and intervention were comparable.

MAIN RESULTS

Thirty one trials met inclusion criteria. Mean methodological quality score was 16.8 (9.5 - 22) out of possible score of 40. Selection criteria varied widely even for the same diagnostic label. There was no uniformity in outcome measures used and their measurement properties were rarely reported. Effect sizes for individual trials were small (-1.4 to 3.0). The results of only three studies investigating "rotator cuff tendonitis" could be pooled. Benefit of subacromial steroid injection over placebo for improving range of abduction (weighted difference between means (WMD) 35 degrees , 95% CI 14 to 55) was the only positive finding.

AUTHORS' CONCLUSIONS

There is little evidence to support or refute the efficacy of common interventions for shoulder pain. As well as, the need for further well designed clinical trials, more research is needed to establish a uniform method of defining shoulder disorders and developing outcome measures which are valid, reliable and responsive in these study populations.

The efficacy of subacromial corticosteroid injection in the treatment of rotator cuff disease: A systematic review

To investigate whether subacromial corticosteroid injections are effective in the treatment of rotator cuff disease, an evidence-based systematic review was undertaken of nine randomized controlled trials that compared subacromial corticosteroid injection with placebo in patients with rotator cuff disease. Each study was systematically evaluated for biases, and outcome measures were scrutinized for statistical significance and clinical importance. One study demonstrated clinically important differences in pain relief. Two studies showed clinically important improvement in range of motion at final follow-up. This systematic review of the available literature indicates that there is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease.

Long term effects of intra-articular botulinum toxin A for refractory joint pain

The purpose of this case series review is to describe our 12 month clinical experience with intra-articular injections of Botulinum toxin Type A (BoNT/A) for refractory joint pain. Eleven patients with chronic arthritis who had failed treatment with oral and/or intra-articular medications and were not surgical candidates were referred to us for management of moderate to severe refractory joint pain in 15 joints. The use of BoNT/A to treat joint pain is a non-FDA approved "off label" treatment with potential side effects. After a detailed explanation of the joint injection procedure, signed informed consent was obtained for the procedure. Fifteen joints were injected with BoNT/A (Allergan, Inc): six lower extremity joints (3 knees, 3 ankles) with 25-50 units and nine shoulders with 50-100 units. Patients were followed for one year or longer. Maximum relief of pain was measured by comparing baseline pain on a numeric rating scale (0-10) to pain at the time of maximum relief (paired t-test). Maximum improvement in function was assessed using paired t-tests for improvement in active flexion and abduction for the shoulder joint, and by the time to perform sit to stand ten times (the timed stands test, TST) for the lower extremity joints.

RESULTS

Two patients were female and nine were male, aged 42-82 years. Five had osteoarthritis (OA), five had rheumatoid arthritis (RA) and one had psoriatic arthritis. All patients were on analgesic and/or anti-inflammatory medications and all joints had previous intra-articular steroid or viscosupplement injections with inadequate or unsatisfactory benefit. A clinically and statistically significant improvement was noted after IA-BoNT/A injections. The mean maximum decrease in lower extremity joint pain was 55% (p =0.02) and the 36% (p =0.044) improvement in the Timed Stands Test was noted at four to ten weeks after injection. There was a 71% mean maximum reduction in shoulder pain severity from 8.2 +/- 1.1 to 2.4 +/- 1.9 (p <0.001). Active range of motion increased 67% in flexion (from 67.8 +/- 27.6 to 113.3 +/- 46.6 degrees, p =0.001) and 42% in abduction (from 50 +/- 18.5 degrees to 71.1 +/- 23.1 degrees p =0.01). No immediate or delayed adverse effects related to BoNT/A were noted after the injection. Duration of pain relief was variable and ranged from 3 to 12 months. Five joints were re-injected with IA-Bont/A and had a similar decrease in joint pain that lasted 3 to 12 months.

CONCLUSIONS

This is the first report of the long term effects of intra-articular BoNT/A injections to treat chronic joint pain and the efficacy of repeated injections. Although this study was small, and uncontrolled the results suggest that IA-BoNT/A injections are an effective and safe treatment for chronic joint pain disorders.

Complications associated with the use of corticosteroids in the treatment of athletic injuries

BACKGROUND

The potent anti-inflammatory pharmacologic effects of the corticosteroids (cortisone and synthetic derivatives) has led to their extensive usage in the management of rheumatologic diseases and athletic musculoskeletal injuries. The efficacy and risks of locally injected or systemically administered corticosteroids in the treatment of athletic injuries are unclear.

OBJECTIVE

To review critically the medical literature and determine complications and risks associated with corticosteroid treatment of athletic injuries.

DATA SOURCES

A search of 3 databases-MEDLINE, CINAHL, and Cochrane Clinical Trial Register-was performed using the OVID interface for all years between 1966 and 2003. The search first combined all references under the medical subject headings adrenal cortex hormones, glucocorticoids, and glucocorticoids, synthetic. A second search combined all references under the medical subject headings athletic injuries, sprains and strains, tendon injuries, shoulder injuries, rotator cuff disease, tennis elbow, and lateral epicondylitis. The references identified by these 2 searches were intersected and limited to human only to produce 130 articles. Relevant review articles were scanned, references reviewed, and additional articles retrieved for consideration of inclusion.

STUDY SELECTION

For inclusion in this critical review, articles must meet the following criteria: (1) subjects were human, (2) subjects had athletic-related injuries, and (3) subjects received corticosteroid treatment. Ultimately, 43 studies met inclusion criteria.

DATA EXTRACTION AND SYNTHESIS

Selected articles were then categorized as to whether the primary focus was usage/efficacy of corticosteroid injection therapy, occurrence of complications of corticosteroid injection therapy, or usage or complications of systemic corticosteroid therapy.

MAIN RESULTS

Twenty-five selected studies primarily examined the usage/efficacy of corticosteroid injections in the treatment of various athletic injuries. Of the 983 total subjects who received corticosteroid injections among these studies, only minor complications of treatment were reported. Eighteen selected studies primarily described complications of corticosteroid injections in the treatment of athletic injuries. Of these, tendon and fascial ruptures were the predominant complications reported. The search identified no articles that addressed the usage of or complications of systemic corticosteroids in the treatment of athletic injuries, although tibial stress fracture and multifocal osteonecrosis occurred in individuals being treated for nonathletic injury conditions.

CONCLUSIONS

This critical review reveals that the existing medical literature does not provide precise estimates for complication rates following the therapeutic use of injected or systemic corticosteroids in the treatment of athletic injuries. Tendon and fascial ruptures are often reported complications of injected corticosteroids, whereas tibial stress fractures and multifocal osteonecrosis were described with systemic corticosteroids.

Randomised trial of long term effect of acupuncture for shoulder pain

The objective of the study is to compare the efficacy of electro-acupuncture with placebo-acupuncture for the treatment of shoulder pain. This study comprised of a prospective, randomized, placebo controlled trial, with independent evaluator set in a Public primary care clinic in Spain. The participants are patients aged from 25 to 83 years with shoulder pain. Patients were randomly allocated to two treatments over eight weeks, with electro-acupuncture or skin non-penetrating placebo-acupuncture, both able to take diclofenac if needed for intense pain. Primary outcome measure was the difference between groups in pain intensity (visual analogue scale-VAS). Secondary outcomes were differences between groups in pain intensity measured by Lattinen index, in range of motion (goniometer), functional ability (SPADI), quality of life (COOP-WONCA charts), NSAIDS intake, credibility (Borkoveck and Nau scale) and global satisfaction (10 points analogue scale). Assessments were performed before, during and three and six months after treatment. At six month follow-up after treatment the acupuncture group showed a significantly greater improvement in pain intensity compared with the control group [VAS mean difference 2.0 (95% CI 1.2-2.9)]. The acupuncture group had consistently better results in every secondary outcome measure than the control group. Acupuncture is an effective long-term treatment for patients with shoulder pain (from soft tissues lesions) in a primary care setting.

Acupuncture for shoulder pain

BACKGROUND

There are many commonly employed forms of treatment for shoulder disorders. This review of acupuncture is one in a series of reviews of varying interventions for shoulder disorders including adhesive capsulitis (frozen shoulder), rotator cuff disease and osteoarthritis. Acupuncture to treat musculoskeletal pain is being used increasingly to confer an analgesic effect and to date its use in shoulder disorder has not been evaluated in a systematic review.

OBJECTIVES

To determine the efficacy and safety of acupuncture in the treatment of adults with shoulder pain.

SEARCH STRATEGY

The Cochrane Controlled Trials Register, MEDLINE, EMBASE and CINAHL were searched from inception to December 2003, and reference lists from relevant trials were reviewed.

SELECTION CRITERIA

Randomised and quasi-randomised trials, in all languages, of acupuncture compared to placebo or another intervention in adults with shoulder pain. Specific exclusions were duration of shoulder pain less than three weeks, rheumatoid arthritis, polymyalgia rheumatica, cervically referred pain and fracture.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted trial and outcome data. For continuous outcome measures where the standard deviations were not reported it was either calculated from the raw data or converted from the standard error of the mean. If neither of these was reported, authors were contacted. Where results were reported as median and range, the trial was not included in the meta-analysis, but presented in Additional Tables. Effect sizes were calculated and combined in a pooled analysis if the study end-points population and intervention were homogenous. Results are presented separately for rotator cuff disease, adhesive capsulitis, full thickness rotator cuff tear and mixed diagnoses, and, where possible, combined in meta-analysis to indicate effect of acupuncture across all shoulder disorders.

MAIN RESULTS

Nine trials of varying methodological quality met the inclusion criteria. For all trials there was poor description of interventions. Varying placebos were used in the different trials. Two trials assessed short-term success (post intervention) of acupuncture for rotator cuff disease and could be combined in meta analysis. There was no significant difference in short-term improvement associated with acupuncture when compared to placebo, but due to small sample sizes this may be explained by Type II error. Acupuncture was of benefit over placebo in improving the Constant Murley Score (a measure of shoulder function) at four weeks (WMD 17.3 (7.79, 26.81)). However, by four months, the difference between the acupuncture and placebo groups, whilst still statistically significant, was no longer likely to be clinically significant (WMD 3.53 (0.74, 6.32)). The Constant Murley Score is graded out of 100, hence a change of 3.53 is unlikely to be of substantial benefit. The results of a small pilot study demonstrated some benefit of both traditional and ear acupuncture plus mobilization over mobilization alone. There was no difference in adverse events related to acupuncture when compared to placebo, however this was assessed by only one trial

AUTHORS' CONCLUSIONS

Due to a small number of clinical and methodologically diverse trials, little can be concluded from this review. There is little evidence to support or refute the use of acupuncture for shoulder pain although there may be short-term benefit with respect to pain and function. There is a need for further well designed clinical trials.

Effects of acupuncture and placebo TENS in addition to exercise in treatment of rotator cuff tendinitis

OBJECTIVE

To compare the effect of acupuncture with placebo transcutaneous electrical nerve stimulation (TENS) when added to the exercise treatment of rotator cuff tendinitis with respect to pain, shoulder movements and function.

DESIGN

Prospective alternate allocation controlled trial.

SETTING

Outpatient department.

PATIENTS

Thirty-three patients (12 women and 21 men) were included in the study. All had clinically diagnosed rotator cuff tendinitis.

INTERVENTION

Both groups underwent a standardized training programme. Each patient received in addition either 10 treatments with acupuncture or placebo TENS, 1-2 times per week.

MAIN OUTCOME MEASURES

The parameters investigated were intensity of pain (measured with visual analogue scale), active, passive as well as functional movements in the shoulder (hand in neck (HIN) and pour out of a pot (POP)). Patients were tested before treatment, after treatment and at a six-month follow-up. Medicine intake, ability to lie on the affected side and sleep disturbances were evaluated. A subjective assessment was made after the treatment and at follow-up.

RESULTS

Sixteen patients had acupuncture, 17 placebo TENS. Eight patients endured pain at rest in the placebo TENS group, and 10 in the acupuncture group. After treatment both groups improved, the improvement persisted at the six-month follow-up. Both groups increased range of movement. Except for the functional test HIN in the acupuncture group, there were no differences between the groups regarding other parameters investigated directly after treatment or at six-month follow-up.

CONCLUSION

There is no difference between the effect of additional acupuncture treatment and placebo TENS in the treatment of rotator cuff tendinitis.

Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review

Prior systematic reviews of rehabilitation for nondescript shoulder pain have not yielded clinically applicable results for those patients with subacromial impingement syndrome (SAIS). The purpose of this study was to examine the evidence for rehabilitation interventions for SAIS. The authors used data source as the method. The computerized bibliographic databases of Medline, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Database of Systematic Reviews were searched from 1966 up to and including October 2003. Key words used were "shoulder," "shoulder impingement syndrome," "bursitis," and "rotator cuff" combined with "rehabilitation," "physical therapy," "electrotherapy," "ultrasound," "acupuncture," and "exercise," limited to clinical trials. Randomized clinical trials that investigated physical interventions used in the rehabilitation of patients with SAIS with clinically relevant outcome measures of pain and quality of life were selected. The search resulted in 635 potential studies, 12 meeting inclusion criteria. Two independent reviewers graded all 12 trials with a quality checklist averaged for a final quality score. The mean quality score for 12 trials was 37.6 out of a possible 69 points. Various treatments were evaluated: exercise in six trials, joint mobilizations in two trials, laser in three trials, ultrasound in two trials, and acupuncture in two trials. The limited evidence currently available suggests that exercise and joint mobilizations are efficacious for patients with SAIS. Laser therapy appears to be of benefit only when used in isolation, not in combination with therapeutic exercise. Ultrasound is of no benefit, and acupuncture trials present equivocal evidence. The low to mediocre methodologic quality, small sample sizes, and general lack of long-term follow-up limit these findings for the development of useful clinical practice guidelines. Further trials are needed to investigate these rehabilitation interventions, the superiority of one intervention over another, and the long-term outcomes of rehabilitation. Moreover, it is imperative that clinical guidelines are developed to indicate those patients who are likely to respond to rehabilitation.

Shoulder injections for osteoarthritis and other disorders

Shoulder injection procedures are powerful diagnostic and therapeutic tools for the care of patients with osteoarthritis and other pathologic conditions of the shoulder-girdle region. Although questions regarding many of the details of the specific procedures still need to be answered, a modest body of literature is available. The musculoskeletal physiatrist is in a good position to contribute to this knowledge base through further clinical research.

Arthrographic joint distension with saline and steroid improves function and reduces pain in patients with painful stiff shoulder: results of a randomised, double blind, placebo controlled trial

OBJECTIVE

To determine whether arthrographic distension with a mixture of saline and steroid, in patients with painful stiff shoulder for at least 3 months, is better than placebo in improving function, pain, and range of motion at 3, 6, and 12 weeks.

METHODS

A randomised, placebo controlled trial with participant and outcome assessor blinding in which shoulder joint distension with normal saline and corticosteroid was compared with placebo (arthrogram). Outcome measures, assessed at 3, 6, and 12 weeks, included a shoulder-specific disability measure (SPADI), a patient preference measure (Problem Elicitation Technique (PET)), pain, and range of active motion.

RESULTS

From 96 potential participants, 48 were recruited. Four withdrew from the placebo group after the 3 week assessment and three subsequently received arthrographic distension with saline and steroid. At 3 weeks, significantly greater improvement in SPADI (p = 0.005), PET, overall pain, active total shoulder abduction, and hand behind back was found in participants in the joint distension and steroid group than in the placebo group. At 6 weeks the results of the intention to treat analysis favoured joint distension, although the between-group differences were only significant for improvement in PET (difference in mean change in PET between groups = 45.9 (95% CI 3.2 to 88.7). Excluding the four withdrawals, the between-group differences for the disability and pain measures significantly favoured distension over placebo. At 12 weeks, both the intention to treat analysis and an analysis excluding the four withdrawals demonstrated a significantly greater improvement in PET score for the distension group.

CONCLUSIONS

Short term efficacy of arthrographic distension with normal saline and corticosteroid over placebo was demonstrated in patients with painful stiff shoulder.

Interventions for tears of the rotator cuff in adults

BACKGROUND

Tears of the rotator cuff tendons, which surround the joints of the shoulder, are one of the most common causes of pain and disability in the upper extremity.

OBJECTIVES

To review the efficacy and safety of common interventions for tears of the rotator cuff in adults.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised trail register (July 2002), the Cochrane Controlled Trials Register (The Cochrane Library issue 2, 2002), MEDLINE (1966 to December 2001), EMBASE (1974 to December 2001), Biological Abstracts (1980 to December 2001), LILACS (1982 to December 2001), CINAHL (November 1982 to December 2001), Science Citation Index and reference lists of articles. We also contacted authors and handsearched conference proceedings focusing on shoulder conditions.

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials involving tears of the rotator cuff were the focus of this review. All trials involving conservative interventions or surgery were included (non-steroidal anti-inflammatory drugs, intra-articular or subacromial glucocorticosteroid injection, oral glucocorticosteroid treatment, physiotherapy, and open or arthroscopic surgery).

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed suitability for inclusion, methodological quality and extracted data. Dichotomous data were presented as relative risks (RR) and 95% confidence intervals (CI), using the fixed effects model.

MAIN RESULTS

Eight trials involving 455 people were included and 393 patients analysed. Trials were grouped in eight categories of conservative or surgical treatment. The median quality score of all trials combined was 16 out of a possible 24 points, with a range of 12-18. In general, included trials differed on diagnostic criteria for rotator cuff tear, there was no uniformity in reported outcome measures, and data which could be summarised were rarely reported. Only results from two studies comparing open repair to arthroscopic debridement could be pooled. There is weak evidence for the superiority of open repair of rotator cuff tears compared with arthroscopic debridement.

REVIEWER'S CONCLUSIONS

There is little evidence to support or refute the efficacy of common interventions for tears of rotator cuff in adults. As well as the need for further well designed clinical trials, uniform methods of defining interventions for rotator cuff tears and validated outcome measures are also essential.

Acupuncture and arthroscopic acromioplasty

BACKGROUND

Acupuncture alleviates acute and chronic shoulder pain. Yet it has not been determined whether acupuncture is useful following musculoskeletal surgery.

HYPOTHESIS

Compared to sham acupuncture, arthroscopic acromioplasty subjects who received real acupuncture would manifest significantly better recovery as demonstrated by: UCLA shoulder scale, improved range of motion, diminished pain, decreased need and duration of analgesic use, and enhanced patient satisfaction.

METHODS

Forty arthroscopic acromioplasty patients were randomized to real or sham acupuncture. UCLA shoulder scale scores, pain intensity, analgesic use, range of motion, and quality of life were monitored for four months. Data were analyzed with the general linear model ANOVA for repeated measures.

RESULTS

Thirty-five subjects completed the study. Real acupuncture subjects scored significantly better on UCLA shoulder scale (p<0.000); pain intensity (p<0.022); self-reported analgesic use (p<0.008); angles of abduction (p<0.046); and in six of eight health status questionnaire components.

CONCLUSIONS

Following arthroscopic acromioplasty, real acupuncture compared to sham acupuncture offered significantly greater improvement via: (1) lower pain level, (2) less analgesic use, (3) range of motion, and (4) patient satisfaction.

Acupuncture for soft tissue shoulder disorders: a series of 201 cases

A retrospective observational study was performed on shoulder pain cases seen in a community general practice. Two hundred and one patients were treated with acupuncture (on distant points plus local shoulder points), moxibustion and auriculotherapy. Data was retrieved from records over a three-year period to assess the effect of acupuncture and moxibustion on pain, mobility and disability, and to compare perceived efficacy rates with published reports from Chinese acupuncturists. Using a four-point outcome scale in this series of 201 patients the study found: one patient (0.5%) reported no improvement, 12 (6%) simple improvement, 68 (33.8%) remarkable improvement, and 120 (59.7%) clinical resolution. Only two patients left the programme. In conclusion, treatment of soft tissue shoulder disorders with acupuncture and moxibustion in this series seems to have good clinical results in diminishing symptoms, shortening disease duration time and improving functional ability, even in long-lasting disease (up to 10 years). A combination of distant points plus local points, moxibustion and auriculotherapy seems to increase effectiveness, reduce the number of sessions per patient, and increase the time between sessions, suiting the needs of patients and those of a busy National Health Service clinic. The authors report results similar to those reported by Chinese acupuncturists when using similar diagnostic procedures, techniques, outcome measures and patients. This case series is the first step towards conducting a randomised controlled trial (RCT) of acupuncture efficacy in shoulder pain. Such trials are needed to confirm the perceived efficacy of acupuncture from observational studies.

Injection therapies for soft-tissue disorders

Local injection therapies are used in the management of a variety of musculoskeletal pain syndromes and include the local infiltration of substances such as corticosteroid and/or anaesthetic, dry needling and neural blockade. Although commonly used, the rationale for their use in many conditions is arguable and evidence of efficacy is often lacking. In this chapter, a number of common injection therapies for soft-tissue-mediated pain are described. The reasoning for their use, potential mechanisms of action and unwanted effects are discussed. The literature relating to their documented effects is critically reviewed. Practical suggestions for their utilization in the management of soft-tissue conditions are given and proposals are made for future research in this important area.

Corticosteroid injections for shoulder pain

BACKGROUND

While many treatments, including corticosteroid injections in and around the shoulder, are advocated to be of benefit for shoulder pain, few are of proven efficacy. This review of corticosteroid injections for shoulder pain is one in a series of reviews of varying interventions for shoulder disorders.

OBJECTIVES

To determine the efficacy and safety of corticosteroid injections in the treatment of adults with shoulder pain.

SEARCH STRATEGY

MEDLINE, EMBASE, CINAHL, Central and Science Citation Index were searched up to and including June 2002.

SELECTION CRITERIA

Randomised and pseudo-randomised trials in all languages of corticosteroid injections compared to placebo or another intervention, or of varying types and dosages of steroid injection in adults with shoulder pain. Specific exclusions were duration of shoulder pain less than three weeks, rheumatoid arthritis, polymyalgia rheumatica and fracture.

DATA COLLECTION AND ANALYSIS

Trial inclusion and methodological quality was assessed by two independent reviewers according to predetermined criteria. Results are presented separately for rotator cuff disease, adhesive capsulitis, full thickness rotator cuff tear and mixed diagnoses, and, where possible, combined in meta-analysis.

MAIN RESULTS

Twenty-six trials met inclusion criteria. The number, site and dosage of injections varied widely between studies. The number of participants per trial ranged from 20 to 114 (median 52 participants). Methodological quality was variable. For rotator cuff disease, subacromial steroid injection was demonstrated to have a small benefit over placebo in some trials however no benefit of subacromial steroid injection over NSAID was demonstrated based upon the pooled results of three trials. For adhesive capsulitis, two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling of any of the trials. One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term (success at seven weeks RR=1.66 (1.21, 2.28).

REVIEWER'S CONCLUSIONS

Despite many RCTs of corticosteroid injections for shoulder pain, their small sample sizes, variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment. Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained. There is a need for further trials investigating the efficacy of corticosteroid injections for shoulder pain. Other important issues that remain to be clarified include whether the accuracy of needle placement, anatomical site, frequency, dose and type of corticosteroid influences efficacy.

Needling therapies in the management of myofascial trigger point pain: a systematic review

OBJECTIVE

To establish whether there is evidence for or against the efficacy of needling as a treatment approach for myofascial trigger point pain.

DATA SOURCES

PubMed, Ovid MEDLINE, Ovid EMBASE, the Cochrane Library, AMED, and CISCOM databases, searched from inception to July 999.

STUDY SELECTION

Randomized, controlled trials in which some form of needling therapy was used to treat myofascial pain.

DATA EXTRACTION

Two reviewers independently extracted data concerning trial methods, quality, and outcomes.

DATA SYNTHESIS

Twenty-three papers were included. No trials were of sufficient quality or design to test the efficacy of any needling technique beyond placebo in the treatment of myofascial pain. Eight of the 10 trials comparing injection of different substances and all 7 higher quality trials found that the effect was independent of the injected substance. All 3 trials that compared dry needling with injection found no difference in effect.

CONCLUSIONS

Direct needling of myofascial trigger points appears to be an effective treatment, but the hypothesis that needling therapies have efficacy beyond placebo is neither supported nor refuted by the evidence from clinical trials. Any effect of these therapies is likely because of the needle or placebo rather than the injection of either saline or active drug. Controlled trials are needed to investigate whether needling has an effect beyond placebo on myofascial trigger point pain.

International research project to devise a protocol to test the effectiveness of acupuncture on painful shoulder

OBJECTIVES

To describe in detail the questions and deliberations leading to the development of a methodologically rigorous protocol to test the effectiveness of acupuncture on painful shoulder.

DESIGN

Randomized controlled trial using three groups, including one control group.

SETTINGS/LOCATION

A hospital in the north of Italy treating at least 8-10 painful shoulders a day, with physician/acupuncturists, physiotherapists, and assessors available to participate in the study.

SUBJECTS

Sixty patients with monolateral painful shoulder. A list of exclusion criteria is given.

INTERVENTIONS

Acupuncture + mobilization; mobilization alone (control); ear acupuncture + mobilization.

OUTCOME MEASURES

Severity of pain, scored on a visual analogue scale (VAS) and on the McGill Pain Questionnaire and restriction of range of motion (ROM) of the shoulder joint. Voluntary use of pain medication, Tenoxicam 20 mg, was added to the protocol.

RESULTS

The research team developed a protocol and methodology that avoids the common flaws and difficulties of previous clinical trials on acupuncture.

CONCLUSIONS

Physicians and acupuncture specialists will benefit from the advice and support of a project group consisting of experienced clinicians, researchers, and statisticians when designing and preparing clinical trials on acupuncture and other complementary and alternative therapies.