Abstract
ObjectiveTo assess the effectiveness of surgical vs conservative interventions on pain and function in patients with subacromial impingement syndrome.DesignSystematic review and meta-analysis of randomized controlled trials.SettingClinical setting.ParticipantsPatients 18 years and older with subacromial impingement syndrome.Intervention/ComparisonSurgical intervention plus postoperative physiotherapy / placebo surgery plus physiotherapy or physiotherapy only.Main outcome measuresPain and function.Results11 RCTs (n = 919) were included. The pooled results displayed no statistically or clinically different between surgery plus physiotherapy vs physiotherapy alone on pain levels at 3-, 6-months, 5- and 10 years follow up (moderate quality, 3 RCTs, 300 patients, WMD -0.39, 95% CI: -1.02 to 0.23, p = 0.22; moderate quality, 3 RCTs, 310 patients, WMD -0.36, 95% CI: -1.02 to 0.29, p = 0.27; low quality, 1 RCT, 109 patients, WMD -0.30, 95% CI: -1.54 to 0.94, p = 0.64; low quality, 1 RCT, 90 patients, WMD -1.00, 95% CI: -0.24 to 2.24, p = 0.11) respectively. Similarly, the pooled results were not statistically or clinically different between groups for function at 3-, 6-month and 1-year follow ups (very low quality, 2 RCTs, 184 patients, SMD 0.11, 95% CI: -0.57 to 0.79, p = 0.75; moderate quality, 3 RCTs, 310 patients, SMD 0.15, 95% CI: -0.14 to 0.43, p = 0.31; very low quality, 2 RCTs, 197 patients, SMD 0.11, 95% CI: -0.46 to 0.69, p = 0.70) respectively.ConclusionThe effects of surgery plus physiotherapy compared to physiotherapy alone on improving pain and function are too small to be clinically important at 3-, 6-months, 1-, 2-, 5- and ≥ 10-years follow up.
Highlights
Shoulder pain is regarded as one of the most frequently reported non-traumatic complaints that arise from the arm, neck and shoulder regions [1], with high prevalence rates across multiple countries [2,3,4,5]
The pooled results displayed no statistically or clinically different between surgery plus physiotherapy vs physiotherapy alone on pain levels at 3, 6months, 5- and 10 years follow up
CI: -1.02 to 0.29, p = 0.27; low quality, 1 Randomized Controlled Trials (RCTs), 109 patients, weighted mean difference (WMD) -0.30, 95% CI: -1.54 to 0.94, p = 0.64; low quality, 1 RCT, 90 patients, WMD -1.00, 95% CI: -0.24 to 2.24, p = 0.11) respectively
Summary
Shoulder pain is regarded as one of the most frequently reported non-traumatic complaints that arise from the arm, neck and shoulder regions [1], with high prevalence rates across multiple countries [2,3,4,5]. The available treatment options for shoulder impingement syndrome include both conservative approaches mainly exercise, and surgical techniques–arthroscopic surgical decompression. The Steuri (2017) systematic review demonstrated that exercise treatment programs yield superior outcomes in pain when compared to non-exercise controls in patients with shoulder impingement (very low quality, 5 RCTs, 189 patients, SMD -0.94, 95% CI: -1.69 to -0.19) [8]. Improvements in function were superior in exercise treatment programs compared to non-exercise controls, (very low quality, 4 RCTs, 202 patients, SMD -0.57, 95% CI: -0.85 to -0.29) [8]. Arthroscopic surgical decompression option may be indicated in patients with persistent severe subacromial shoulder pain along with functional limitations that have not improved in response to conservative treatment options [9]. The Steuri (2017) review indicated that there was insufficient evidence to display whether exercise is as good as surgery [8]
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