Author Names
Gebremariam, L; Hay, E; van der Sanske, R; Rinkel, W; Koes, B; Huisstede, B
Reviewer Name
Chance Thomas Thorkelson SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy
Paper Abstract
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.
NIH Risk of Bias Tool
Quality Assessment of Systematic Reviews and Meta-Analyses
- Is the review based on a focused question that is adequately formulated and described?
- Yes
- Were eligibility criteria for included and excluded studies predefined and specified?
- Yes
- Did the literature search strategy use a comprehensive, systematic approach?
- Yes
- Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
- Yes
- Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
- Were the included studies listed along with important characteristics and results of each study?
- Yes
- Was publication bias assessed?
- No
- Was heterogeneity assessed? (This question applies only to meta-analyses.)
- Yes
Key Finding #1
The article found that mobilization as an add-on treatment to exercise was significantly better at decreasing pain and improving composite strength. Another RCT found similar benefits in reducing pain but no significant difference in ROM.
Key Finding #2
The evidence for manual therapy was limited in this patient population and needs further research to better understand the role it can have on recovery. Clearer research was found in support for exercise therapy.
Key Finding #3
An article looked at the effectiveness of manual therapy compared to self-training and saw a significant decrease in pain after 12 weeks, but limited evidence was shown in the short term.
Please provide your summary of the paper
This article gathered relevant research that compared the benefits of non-surgical interventions on subacromial impingement syndrome (SIS) to surgical procedures. Two reviewers sifted through the relevant literature and used a best-evidence synthesis to summarize the results. Two reviews and ten RCTs met the inclusion criteria. The nature of the different articles included looked at interventions such as US, laser, Exercise, and manual therapy techniques. The article found the most supported intervention to be hyperthermia and manual therapy techniques possessed limited evidence. The article discussed some of the limitations this review possesses such as smaller scale studies, and potential bias in assigning studies a title of high-quality. The emphasis was placed in a need for a more large-scale study to better understand proper clinical decision making.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
The scarcity of research pertaining to a major diagnosis of the shoulder highlights further needs in pushing our profession to find best practices that will help our patients. The two articles that referenced manual therapy found benefits in reducing the subject’s level of pain. This finding has great benefit for PT as we work to find stronger research to support the need for these treatments physiologically. With a decreased reporting of pain patients will be more likely to return to previous levels of function, adhere to training programs, and work at improving noted impairments. Manual therapy can be a means of facilitating further intervention progression as well as avoid the decision to participate in surgical interventions and their risk factors. PTs can look to implement manual techniques to aid patients in overcoming the barrier of pain and ultimately participate in interventions such as functional training.
