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REVIEW ARTICLE (META-ANALYSIS)

Effectiveness of Surgical and Postsurgical Interventions for the


Subacromial Impingement Syndrome: A Systematic Review
Lukas Gebremariam, MD, Elaine M. Hay, FRCP, MD, Bart W. Koes, PhD, Bionka M. Huisstede, PhD
ABSTRACT. Gebremariam L, Hay EM, Koes BW, Huisstede BM. Effectiveness of surgical and postsurgical interventions for the subacromial impingement syndrome: a systematic
review. Arch Phys Med Rehabil 2011;92:1900-13.
Objective: To provide an evidence-based overview of the
effectiveness of surgical and postsurgical interventions for the
subacromial impingement syndrome.
Data Sources: The Cochrane Library, PubMed, Embase,
PEDro, and CINAHL were searched.
Study Selection: Two reviewers independently selected relevant systematic reviews and randomized controlled trials
(RCTs).
Data Extraction: Two reviewers independently extracted data
and assessed the methodologic quality.
Data Synthesis: If pooling of data was not possible, a bestevidence synthesis was used to summarize the results.
Results: One review and 5 RCTs reporting on various surgical techniques, and postsurgical interventions were included.
Moderate evidence was found in favor of adding plateletleukocyte gel versus open subacromial decompression. No
evidence was found for the superiority of subacromial decompression versus conservative treatment in the short, mid, and
long term or in favor of 1 surgical technique when compared
with another. Limited evidence was found in favor of early
activation after arthroscopic decompression in the short and
long term.
Conclusions: This review shows that there is no evidence that
surgical treatment is superior to conservative treatment or that1
particular surgical technique is superior to another. Because of
possibly lower risks for complications, conservative treatment
may be preferred. When choosing for surgery, arthroscopic
decompression may be preferred because of the less invasive
character of the procedure.
Key Words: General surgery; Rehabilitation; Shoulder;
Shoulder impingement syndrome; Treatment outcome.
2011 by the American Congress of Rehabilitation
Medicine

HE SUBACROMIAL IMPINGEMENT syndrome (SIS)


T
includes a number of pathologic entities: rotator cuff syndrome, tendonitis, and bursitis in the shoulder. SIS occurs
1

when the soft tissues of the glenohumeral joint between the


coracoacromial arch and the humeral tuberosity are com-

pressed, disturbing the normative sliding mechanism when


elevating the arm. Patients visiting their general practitioner
with Complaints of the Arm, Neck and/or Shoulder (CANS),1
that is, nontraumatic musculoskeletal complaints of the upper
extremity not caused by any systemic disease, frequently report
shoulder complaints2; 33% of those with CANS are diagnosed
with SIS.3
Work-related factors associated with the occurrence of SIS
include handling of loads frequently or with high force, highly
repetitive work, hand-arm vibration, work above shoulder
level, and high job demands (high work pressure and high
emotional demands).4
Affected patients complain of anterolateral shoulder pain
that is worsened by active lifting of the arm into the impingement arc (60120 of shoulder abduction).5 Also pain at night
is frequently reported, exacerbated by lying on the involved
shoulder, or sleeping with the arm overhead.6
Various physical tests for diagnosing SIS have been described, but it remains difficult for physicians to differentiate
between the different types of tendonitis and bursitis around the
shoulder.1 According to Park et al,7 the best combination of
physical tests to diagnose SIS is a positive Hawkins-Kennedy
impingement sign (pain and resulting facial expression when
applying forward flexion of the shoulder to 90 and internal
rotation), a positive painful arc sign, and weakness in external
rotation with the arm at the side. However, although physical
tests are important, they may not be sufficient for appropriate
diagnosis, because most tests for SIS have greater sensitivity
than specificity.8 Therefore, in addition to the patient history,
physical examination findings, and specific impingement test
maneuvers (eg, Neer and Hawkins-Kennedy), radiologic evaluation with ultrasound and magnetic resonance imaging is
recommended.8
Current accepted approaches to treat SIS include both conservative and surgical management.9 Having clinical symptoms
for over 1 year10 and the severity of symptoms were reported
to be prognostic factors for a negative outcome on conservative
intervention.9,10 When conservative approach fails, surgical
treatment is considered.
Currently there is no review that solely concentrates on the
effectiveness of interventions for SIS only. One Cochrane
review11 concentrates on surgical interventions to treat rotator
cuff disease. Since the publication of the Cochrane review, new

List of Abbreviations
From the Departments of General Practice (Gebremariam, Koes, Huisstede); and
Rehabilitation Medicine (Huisstede), Erasmus MC University Medical Center
Rotterdam, Rotterdam, The Netherlands; the Arthritis Research Campaign National
Primary Care Centre, Keele University, Keele, United Kingdom (Hay).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.
Reprint requests to Bionka M.A. Huisstede, PhD, Erasmus MC University
Medical Center Rotterdam, Dept of Rehabilitation, Room H-016, PO Box 2040, 3000
CA Rotterdam, The Netherlands, e-mail: b.huisstede@erasmusmc.nl.
0003-9993/11/9211-00260$36.00/0
doi:10.1016/j.apmr.2011.06.006

Arch Phys Med Rehabil Vol 92, November 2011

ASD
ASES
CANS
OSD
PLG
RCT
ROM
SIS
UCLA

arthroscopic subacromial decompression


American Shoulder and Elbow Surgeons
Complaints of the Arm, Neck and/or Shoulder
open subacromial decompression
platelet-leukocyte gel
randomized controlled trial
range of motion
subacromial impingement syndrome
University of California at Los Angeles

SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME, Gebremariam


Table 1: Methodologic Quality Assessment: Sources of Risk Bias
Items Risk of Bias
1. Was the method of randomization adequate?
2. Was the treatment allocation concealed?
3. Was the patient blinded to the intervention?
4. Was the care provider blinded to the intervention?
5. Was the outcome assessor blinded to the intervention?
6. Was the dropout rate described and acceptable?
7. Were all randomized participants analyzed in the group to
which they were allocated?
8. Are reports of the study free of suggestion of selective
outcome reporting?
9. Were the groups similar at baseline regarding the most
important prognostic indicators?
10. Were cointerventions avoided or similar?
11. Was the compliance acceptable in all groups?
12. Was the timing of the outcome assessment similar in all
groups?

RCTs have been published, and we wondered whether the


conclusions made in the Cochrane review would remain the
same or would need modification. In order to further optimize
the quality of care for patients with SIS given by clinicians and
paramedical staff, an overview regarding evidence-based information is needed that can support developing evidencebased treatment protocols and guidelines. The aim of the present study is to provide an evidence-based overview of the
effectiveness of surgical and postsurgical interventions for SIS.
METHOD
Search Strategy
To identify relevant systematic reviews and randomized
controlled trials (RCTs) on SIS, a search was performed in the
Cochrane Library, PubMed, Embase, PEDro, and CINAHL up
to February 2009. Key words such as shoulder impingement
syndrome and rotator cuff impingement and interventions were
included in the literature search (appendix 1).
Inclusion Criteria
Systematic reviews and/or RCTs were considered eligible
for inclusion if: (1) the study included patients with SIS, (2)
SIS was not caused by an acute trauma or any systemic disease
as described in the definition of CANS, (3) an intervention,
including a postsurgical intervention, for treating SIS was
evaluated, (4) results on pain, function, or recovery were reported, and (5) a follow-up period of at least 2 weeks was
reported. There were no language restrictions.

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describes all RCTs concerning an intervention that has not yet


been described in a systematic review.
Data Extraction
Two authors (L.G. and B.H.) independently extracted the
data of the included studies. Information was collected on the
study population, interventions, and outcome measures. The
outcome evaluation was determined as short term if it occurred
in less than 3 months (after baseline), middle term between 4
and 6 months, and long term when the follow-up period was
longer than 6 months.
Methodologic Quality Assessment
To identify potential risks of bias of the included RCTs, 2
reviewers independently assessed the methodologic quality of
each RCT, using the 12 quality criteria (table 1) of Furlan et
al.12 Each item was scored as yes, no, or unclear. High quality
was defined as a yes score of 50% or more. A consensus
procedure was used to solve disagreement between the reviewers.
In a (Cochrane) review the use of a methodologic quality
assessment is a standard procedure. We describe the methodologic quality scale or criteria that were used in the review, and
have used their definitions of high and low quality of the
included studies.
Data Synthesis
A quantitative analysis of the studies was not possible due to
heterogeneneity of the outcome measures or study population.
Therefore, we summarized the results using a rating system
that consisted of 5 levels of scientific evidence (ie, best-evidence synthesis)13 (table 2). An article was included in the
best-evidence synthesis if a comparison was made between
the study groups (treatment vs placebo/control/treatment),
and the level of significance was reported. The study results
were labeled significant if it reported significant results on 1
of the 3 outcomes.
RESULTS
Study Characteristics
The initial literature search identified 5 reviews via the
Cochrane Library, 5 reviews/215 RCTs via PubMed, 21 reviews/193 RCTs via Embase, 141 reviews/RCTs via CINAHL,
and 0 reviews/13 RCTs via PEDro were identified. Finally, 1
Cochrane review and 5 RCTs (all found in PubMed) were
included. The Cochrane review of Coghlan et al,11 studying the
effectiveness of surgery for rotator cuff disease, included 14
trials; 11 (n611) of these studies reported on SIS (including

Table 2: Levels of Evidence

Study Selection
Two reviewers (L.G. and B.H.) independently applied the
inclusion criteria to select potential relevant studies from the
title and abstracts of the references retrieved by the literature
search. A consensus method was used to solve any disagreements concerning inclusion of studies, and a third reviewer
(B.K.) was consulted if disagreement persisted.
Categorization of the Relevant Literature
Relevant literature is categorized under 3 different headers:
Systematic reviews describes all (Cochrane) reviews; Recent
RCTs contains all RCTs published after the search date of the
systematic review on the same intervention; Additional RCTs

Strong evidence: consistent (ie, when 75% of the trials report


the same findings), positive (significant) findings within multiple
higher quality RCTs.
Moderate evidence: consistent, positive (significant) findings
within multiple lower quality RCTs and/or 1 high-quality RCT.
Limited evidence for effectiveness: positive (significant) findings
within 1 low-quality RCT.
Conflicting evidence: provided by conflicting (significant) findings
in the RCTs (75% of the studies reported consistent findings).
No evidence: RCT(s) available, but no (significant) differences
between the intervention and control groups were reported.

Arch Phys Med Rehabil Vol 92, November 2011

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Arch Phys Med Rehabil Vol 92, November 2011

calcific tendinitis) and met our inclusion criteria. Figure 1


shows the process of identifying the relevant articles. Furthermore, we included 5 additional RCTs: 2 studying surgery and
3 studying postsurgical interventions. Appendices 2, 3, and 4
show characteristics of the included studies.

Abbreviations: , yes; -, no; ?, unclear/unsure; ITT, intention-to-treat; NA, not applicable (in a nontime intervention, eg, surgery, compliance is not an issue).

33
4
?

?
?

12

42
5

12

42
5

12

55
6

NA

11

82
9
11

NA

Everts
et al26
Taverna
et al25
Hultenheim
Klintberg
et al27
Jarvela
et al29
Hoe-Hansen
and
Norlin28

Reference

Blinding?
Outcome
Assessors?
Blinding?
Patients?
Adequate
Randomization?

Allocation
Concealment?

Blinding?
Caregiver?

Score
Study
Cointerventions
Avoided or
Similar?
Free of
Suggestions
Similarity of
of Selective
Baseline
Outcome
Reporting? Characteristics?
Incomplete
Outcome
Data? ITT
Analysis?
Incomplete
Outcome
Data
Addressed?
Dropouts?

Table 3: Methodologic Quality Scores of the Included Recent and Additional RCTs

Timing of
the
Outcome
Compliance
Acceptable in Assessment
Similar?
all Groups?

Maximum
Score

SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME, Gebremariam

Methodologic Quality
Tables 3 and 4 present the results of the methodologic
quality assessment.
Two of the 5 included RCTs were classified as high quality.
The 3 low-quality RCTs scored 33% to 42% of the total score.
The most prevalent methodologic flaws were: (1) care provider
not blinded (75%) (as expected in surgery) and (2) no intention-to-treat analysis (75%) was applied by the authors of the
RCTs. According to the authors of the Cochrane review,11 10
of the 11 RCTs had a high risk of bias, and 1 RCT had a
medium to high risk of bias; 6 items were used to score the
methodologic quality of these studies.
Effectiveness of Surgical and Postsurgical Interventions
to Treat SIS
A complete overview of the evidence is presented in table 5.
1. Effectiveness of Surgery
1.1. Arthroscopic or Open Subacromial Decompression
Versus Conservative Treatment
Systematic review. Three trials (n258) compared either
open14 or arthroscopic15,16 surgery with active nonoperative
treatment. The low-quality study of Haahr et al16 (n90) found
no differences between arthroscopic subacromial decompression and a graded physiotherapy strengthening program on the
mean change in Constant score at 3, 6, and 12 months. Furthermore, there were no significant differences between the 2
treatment groups for the PRIM score (aggregated pain and
dysfunction score used in Projects on Research and Intervention in Monotonous work) at 12 months, or between the number of participants with a good or excellent Constant score
(80) at 12 months.
A low-quality trial14 (n42) compared open subacromial decompression and a physiotherapy program of exercise and education. At 6- and 12-month follow-up, there were no significant
differences between the groups for the number of participants who
reported success of treatment or of those reporting success and
partial success of treatment.
Another low-quality study15 (n125) reported no differences in
median Neer score between surgery and an exercise program at 3and 6-month follow-up. No differences in the median pain scores
(pain on activity, pain at rest, and pain at night) were reported
between surgery and nonoperative treatment. Therefore, these
low-quality trials found no evidence for the effectiveness of surgery (open or arthroscopic) compared with conservative treatment
for treating SIS in the short, mid, and long term.
1.2. Arthroscopic Versus Open Subacromial
Decompression
Systematic review. Five trials17-21 (n248) compared arthroscopic (ASD) versus open subacromial decompression
(OSD) for SIS. A low-quality trial17 (n32) found no differences between the groups on pain at rest at 3-, 6-, and 12-month
follow-up. Also, on pain with activity and the mean University
of California and Los Angeles (UCLA) shoulder rating scale
score no significant differences between ASD and OSD were
found at 3-,17 6-,17 12-,17-18 or 96-month17 follow-up.

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SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME, Gebremariam

Fig 1. Flowchart of the literature


search.

A low-quality trial19 (n44) reported equivalent pain scores


for both groups at time points up to 1 year. Also, in another
low-quality trial20 (n46) there were no significant differences
on the mean UCLA shoulder rating scale score between ASD
and OSD (follow-up time unclear).
Two low-quality trials20,21 (n97) reported no significant
differences between the groups on the proportion of participants with a good or excellent UCLA shoulder rating scale
score. The Constant score, measured in a low-quality trial,18
showed no significant difference between ASD and OSD.
Further, no differences between both groups on range of

motion (ROM) were found at 1-year follow-up. In 2 lowquality trials17,19 no significant differences were found between ASD and OSD for muscle strength, at any evaluation
period.
Therefore, there is no evidence for the effectiveness of ASD
and OSD in the short, mid, and long term.
1.3. OSD: Neer Versus Modified Neer Technique
One low quality trial22 reported differences in abduction
between the Neer and modified Neer technique in OSD after 8
weeks, but this could not be verified from the data.

Table 4: Methodologic Quality Scores of the Included Cochrane Review of Coghlan et al11

Reference

Brox et al15
Haahr et al16
Husby et al17
Murphy et al24
Iversen et al20
Rahme et al14
Spangehl et al21
TJonck et al18
Ingvarrson et al22
Rubenthaler23
Sachs et al19

Allocation
Blinding
Randomization? Concealment? Patients?

?
?
?
?
?

?
?
?
?
?
?
?

?
?
?

Blinding?
Outcome
Assessors?

?
?
?

Acceptable?
No. Lost
Intention-to-Treat
Score
Score
to Follow-up?
Analysis?
Maximum Study

NS
NS

NS

NS
?
NS

6
6
6
6
6
6
6
6
6
6
6

4
4
4
2
2
2
2
2
1
1
1

Overall
Validity

Quality
of the
Study

66
66
66
33
33
33
33
33
17
17
17

C
BC
C
C
C
C
C
C
C
C
C

Low
Low
Low
Low
Low
Low
Low
Low
Low
Low
Low

Abbreviations: , yes; -, no; ?, unclear; No. lost to follow-up, we defined this item positive if the percentage of lost to follow-up is 20% for
the short-term follow-up and 30% for the long-term follow-up; NS, not stated but participants completed within their surgical allocation;
Overall validity, A (low risk of bias), all criteria met; B (moderate risk of bias), 1 or more criteria partly met; C (high risk of bias), 1 or more
criteria not met.

Arch Phys Med Rehabil Vol 92, November 2011

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SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME, Gebremariam


Table 5: CANS: Evidence for Effectiveness of Surgical and Postsurgical Interventions for Subacromial Impingement Syndrome
Surgery vs Conservative

ASD or OSD vs conservative:


Short term
Mid term
Long term

Postsurgery

NE
NE
NE

Ketoprofen* after ASD vs control:


Short term
Long term

NE

Early activation* vs protective activation


physiotherapy after ASD
ASD vs OSD:
ASD vs OSD:
Short term
Mid term
Long term
ASD vs OSD for removal of calcium deposits:
Short term
Mid term
OSD:
Neer vs modified Neer technique:
Short term
ASD:
ASD using electrocautery* vs using a Holium laser:
Short term
Mid term
Long term
ASD vs radiofrequency-based plasma microtenotomy:
Short term
Mid term
Long term
In surgery:
PLG* vs control in OSD
Short term

NE
NE
NE

Short term
Long term
Pain pump vs control after ASD:
Long term

NE

NE
NE

NE

NE
NE
NE
NE

Abbreviations: , limited evidence found; , moderate evidence found; NE, no evidence found for effectiveness of the treatment: RCT(s)
available, but no differences between intervention and control groups were found.
*In favor of.

There is no evidence for effectiveness of the Neer versus the


modified Neer technique in OSD.
1.4. ASD Versus OSD to Remove Calcium Deposit in
Calcific Tendonitis
Systematic review. A low-quality study23 (n38) compared
ASD and OSD to remove calcium deposits in patients with calcific
tendonitis. No significant differences between the groups were
reported on pain relief and subjective ratings of shoulder function
at 16-month follow-up or average duration of postoperative physiotherapy. There is no evidence for the effectiveness of ASD
compared with OSD to remove calcium deposits in patients with
calcific tendonitis in the short and mid term.
1.5. Electrocautery Versus Holium Laser in ASD
Systematic review. A low-quality study24 (n49) compared
2 different ASD techniques: holium laser versus electrocautery.
No significant results were found on the UCLA shoulder rating
scale scores at 3-, 6-, and 12-month follow-up. A small significant
difference between the groups in favor of the electrocautery group
was found in the American Shoulder and Elbow Surgeons (ASES)
score at 6-month follow-up (weighted mean difference, 8.00;
95% confidence interval, 15.62 to 0.38). No significant differences between the groups on the ASES score were found at 3and 12-month follow-up. There is limited evidence for the effectiveness of electrocautery compared with the holium laser in ASD
in the short and mid term and no evidence for the long term.
Arch Phys Med Rehabil Vol 92, November 2011

1.6. ASD Versus Radiofrequency-Based Plasma


Microtenotomy
Recent RCT. A high-quality study25 (n60) examined ASD
versus radiofrequency-based plasma microtenotomy. After 3, 6,
and 12 months, no significant differences were found between the
groups for the visual analog scale, ASES, UCLA shoulder rating
scale, and the Constant score. Therefore, there is no evidence for
the effectiveness of ASD versus radiofrequency-based plasma
microtenotomy to treat SIS in the short, mid, and long term.
1.7. Platelet-Leukocyte Gel as Add-On Therapy in OSD
Additional RCT. A high-quality RCT26 (n40) studied the
effect of platelet-leukocyte gel (PLG) on postoperative recovery of patients undergoing OSD. Only patients in the treatment
group were injected with PLG. Six weeks postoperatively, the
PLG group showed a significant (P.001) decrease in pain
compared with the control group (no exact data given). Further,
a significantly better shoulder index score (P.001) was found
in favor of the PLG group compared with the controls at
6-weeks follow-up (no exact data given). There were no significant differences (P.13) on shoulder instability scores between the 2 groups at 6-weeks follow-up. The PLG group
showed significantly (P.05) more activities in daily living
than the control group and showed significantly (P.001)
improved ROM at 12-weeks follow-up (no exact data given).
Therefore, there is moderate evidence for the effectiveness of

SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME, Gebremariam

PLG on postoperative recovery of patients undergoing OSD in


the short-term.
2. Effectiveness of Postsurgery Treatments
2.1. Early Activation Versus Protective Physiotherapy
After ASD
Additional RCT. A low-quality RCT27 compared 2 different physiotherapy protocols in patients (n33) with SIS who
had ASD. A traditional group received active assisted dynamic
exercises for the rotator cuff 6 weeks after operation (3 times
per day) and strengthening exercises 8 weeks after operation. A
progressive group received active assisted ROM exercises 1
day after operation (3 times per day) and strengthening exercises 6 weeks after operation (3 times per day). Both groups
showed significant improvements in pain during activity and at
rest at 12-month follow-up. There were also significant
(P.05) improvements in ROM in extension and abduction
between the groups at 3- and 12-month follow-up in favor of
the progressive group. The Constant score was significantly
(P0.05) higher in the progressive group at 6-weeks followup, but not at 3-month follow-up. There is limited evidence for
the effectiveness of progressive physiotherapy in the short and
long term compared with traditional physiotherapy.
2.2. Ketoprofen Versus Placebo After ASD
Additional RCT. A low-quality study28 compared ketoprofen 200mg once daily for 6 weeks (n21) with the placebo
(n20) in patients who had ASD. After 6 weeks, the number
of patients showing mild or no pain was significantly higher in
the ketoprofen group compared with the placebo group (ketoprofen: 16 of 19 vs placebo: 9 of 19, P.005). Further, significant results (P.05) were reported in favor of the ketoprofen group on the UCLA shoulder rating scale score, active
forward flexion, and active abduction at 6-weeks follow-up.
These significant differences on the short term did not sustain
at 2-years follow-up. Therefore, there is limited evidence for
ketoprofen after ASD in the short-term and no evidence in the
long-term.
2.3. Pain Pump After ASD
Additional RCT. A low-quality RCT29 compared the use
of a pain pump with 0.375% ropivacaine after ASD as add-on
therapy with a rehabilitation group (n50). At 2-years followup, no significant differences were found between the groups
on the UCLA shoulder rating scale score (P.845) and on the
Constant score (P.243).
There is no evidence in the long term for the effectiveness of
a pain pump as add-on therapy to rehabilitation after ASD in
patients with SIS.
DISCUSSION
In general, patients failing to respond to conservative treatments are considered for surgery. In the present review no
evidence was found for the superiority of subacromial decompression (arthroscopic or open) compared with conservative
treatment in the short, mid, and long term. However, our
conclusion is based on only 3 low-quality studies that included
a small number of patients. Although no significant results
were found between surgery and conservative treatment, 1
study16 found better within-group results (ie, significant outcome when the pre- and posttreatment results were compared)
in the conservative group, and another study15 found better
within-group results in the surgery group. The third study

1905

stated that if an intention-to-treat analysis was conducted, the


effectiveness of surgery should be favorable.14
In general, surgical interventions for treating subacromial
impingement are associated with more complications and
higher costs than conservative treatment.15 One review found
exercise therapy to be 1 of the most effective conservative
intervention to treat SIS in the short and mid term (Gebremariam, unpublished data, 2011). More studies are needed to
further elucidate the evidence for differences in outcome between surgery and conservative interventions.
If patients are treated surgically, either OSD or ASD can be
performed. In the present review no evidence was found for the
superiority of ASD or OSD in the short, mid, and long term.
This conclusion is based on 5 low-quality studies with relatively small groups of patients. ASD tends to give a faster
recovery due to its less invasive nature.19,30 No trials were
found that focused on defining an optimal timing strategy for
surgery; future studies should focus on this important topic.
For within-surgery techniques, moderate evidence was
found for the effectiveness of PLG as add-on therapy to OSD,
and limited evidence was found for using electrocautery in
ASD versus using the holium laser.
Only a few RCTs were found studying postsurgical management. Limited evidence was found in favor of early activation
after ASD versus protective activation in the short and long
term, and for ketoprofen after ASD in the short term (although
the latter effect did not sustain in the long term). Thus, if
surgery is required, it seems that postsurgical intervention can
influence the outcome of surgery.
Study Limitations
This review has some limitations. In general, the methodologic quality of the included studies was low; only 2 highquality RCTs were found. This may be a result of inadequate
reporting in the studies. Four of the 5 included RCTs failed to
mention allocation concealment and whether or not cointerventions were avoided or similar.
The included Cochrane review of Coghlan et al11 used
different methodologic quality criteria compared with our criteria based on Furlan et al.12 Because of the high credibility and
validity of Cochrane reviews, we decided to apply the methodologic quality criteria and definitions of high-quality and
low-quality studies used in a Cochrane review. However, the
quality criteria of the Cochrane reviews11 included fewer items
than our 12 quality criteria, and high quality was not defined as
at least 50% of the items were scored positive. This could
contribute to bias in the outcome of evidence and conclusions.
If we would we have used our definition that a study is
classified as high quality if at least 50% of the items were
scored positive, 3 of the 11 RCTs would have been classified as
high-quality studies (see table 3). However, in this case, our
conclusions regarding the evidence for effectiveness of the
interventions would remain similar.
Further, it should be addressed that the power of some
studies was low, because only a small number of patients were
included; maybe because of this, no statistically significant
differences between the groups were found.
CONCLUSIONS
This review shows that there is no evidence that surgical
treatment is superior to conservative treatment or that 1 particular surgical technique is superior to another to treat SIS.
Because of lower costs and possibly lower risk of complications, conservative treatment may be preferred to surgery.
When choosing surgery, arthroscopic decompression may be
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SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME, Gebremariam

preferred because of the faster recovery of ROM and the


minimally invasive character of the procedure. Furthermore,
early activation postsurgery might have positive results but
additional studies are required to confirm this statement.
Acknowledgement: We thank M.S. Randsdorp (MR), MD, for
her participation in the quality assessment.

APPENDIX 1: SEARCH STRATEGY


PubMed
SIS shoulder impingement syndrome[mh] OR rotator
cuff[mh] OR rotator cuff OR (subacrom* AND impingement) OR (shoulder AND impingement) OR ((shoulder OR shoulder pain[mh] OR supraspinatus OR supraspinatus OR infraspinatus OR infra-spinatus OR
subscapularis OR sub-scapularis OR teres minor) AND
(tendinopathy[mh:noexp] OR tenovaginitis OR tendovaginitis OR tendinit* OR tendonitis OR tenosynovitis OR
tendinos* OR bursitis[mh:noexp])).
Therapy (randomized controlled trial[Publication Type] OR
(randomized[Title/Abstract] AND controlled[Title/Abstract] AND trial[Title/Abstract])).
Systematic reviews ((meta-analysis [pt] OR meta-analysis
[tw] OR metanalysis [tw]) OR ((review [pt] OR guideline
[pt] OR consensus [ti] OR guideline* [ti] OR literature [ti]
OR overview [ti] OR review [ti]) AND ((Cochrane [tw]
OR Medline [tw] OR CINAHL [tw] OR (National [tw]
AND Library [tw])) OR (handsearch* [tw] OR search*
[tw] OR searching [tw]) AND (hand [tw] OR manual [tw]
OR electronic [tw] OR bibliographi* [tw] OR database*
OR (Cochrane [tw] OR Medline [tw] OR CINAHL [tw]
OR (National [tw] AND Library [tw]))))) OR ((synthesis
[ti] OR overview [ti] OR review [ti] OR survey [ti]) AND
(systematic [ti] OR critical [ti] OR methodologic [ti] OR
quantitative [ti] OR qualitative [ti] OR literature [ti] OR
evidence [ti] OR evidence-based [ti]))) BUTNOT (case*
[ti] OR report [ti] OR editorial [pt] OR comment [pt] OR
letter [pt]).
RCTs (randomized controlled trial [pt] OR controlled clinical trial [pt] OR randomized controlled trials [mh] OR
random allocation [mh] OR double-blind method [mh] OR
single-blind method [mh] OR clinical trial [pt] OR clinical
trials [mh] OR clinical trial [tw] OR ((singl* [tw] OR
doubl* [tw] OR trebl* [tw] OR tripl* [tw]) AND (mask*
[tw] OR blind* [tw])) OR latin square [tw] OR placebos
[mh] OR placebo* [tw] OR random* [tw] OR research
design [mh:noexp] OR comparative study [mh] OR evaluation studies [mh] OR follow-up studies [mh] OR prospective studies [mh] OR cross-over studies [mh] OR control* [tw] OR prospectiv* [tw] OR volunteer* [tw]) NOT
(animal [mh] NOT human [mh]).

Arch Phys Med Rehabil Vol 92, November 2011

Embase
SIS shoulder impingement syndrome/OR ((shoulder/OR
shoulder) AND impingement) OR rotator cuff/OR rotator
cuff OR (subacrom* AND impingement) OR ((shoulder/OR
shoulder OR supraspinatus OR supra-spinatus OR infraspinatus OR infra-spinatus OR subscapularis OR sub-scapularis
OR teres minor) AND (tendinopathy OR tendovaginitis OR
tendovaginitis/or tendinit* OR tendonitis OR tendinitis/OR
tenosynovitis/OR tendinos* OR bursitis/)).
Therapy randomized controlled trial:it OR (randomized:
ti,ab AND controlled:ti,ab AND trial:ti,ab).
Systematic reviews (review/exp AND (medline:ti,ab OR
medlars:ti,ab OR embase:ti,ab OR pubmed:ti,ab) OR
scisearch:ti,ab OR psychlit:ti,ab OR psyclit:ti,ab OR psycinfo:
ti,ab OR pyschinfo:ti,ab OR cinahl:ti,ab OR hand search:
ti,ab OR manual search:ti,ab OR electric database:ti,ab OR
bibliographic database:ti,ab OR pooled analysis:ti,ab OR
pooled analyses:ti,ab OR pooling:ti,ab OR peto:ti,ab OR
dersimonian:ti,ab OR fixed effect:ti,ab OR mantel haenszel:ti,ab OR retracted article:ti,ab) OR (meta analysis/
exp OR meta analysis OR meta-analysis OR meta-analyses:ti,ab OR meta analyses:ti,ab OR systematic review:
ti,ab OR systematic overview:ti,ab OR quantitative
review:ti,ab OR quantitativ overview:ti,ab OR methodologic review:ti,ab OR methodologic overview:ti,ab OR integrative research review:ti,ab OR research integration:ti,ab
OR quantitative synthesis:ti,ab).
RCTs (controlled clinical trial/exp OR randomized controlled trial:ti OR controlled clinical trial:it OR randomization/OR double blind procedure/OR single blind procedure/OR crossover procedure/OR clinical trial:it OR
((clinical trial OR (singl* OR doubl* OR tripl*)) AND
(mask* OR blind*)) OR (Latin square design/OR latin
square OR latin-square) OR placebo/OR placebo* OR
random sample/OR comparative study:it OR evaluation study:it OR evaluation/exp OR follow up/exp OR
prospective study/OR control* OR prospectiv* OR volunteer*) NOT (animals/exp NOT humans/exp).
CINAHL
SIS (MH Shoulder impingement syndrome) or (MH rotator cuff)or rotator cuff or (subacrom* and impingement) or (((MH shoulder) or (MH shoulder joint) or
shoulder) and impingement) or (((MH shoulder) or (MH
shoulder joint) or shoulder or (MH shoulder pain) or
supraspinatus or supra-spinatus or infraspinatus or infraspinatus or subscapularis or sub-scapularis or teres minor) and ((MH Tendinitis) or (MH tenosynovitis) or
tend* or tenovaginitis or tendovaginitis)).
Reviews (MH Systematic Review).
Clinical trials (MH Clinical Trials).
PEDro
SIS Subacromial impingement syndrome, Rotator cuff syndrome, impingement syndrome Table a1, a2, a3.

APPENDIX 2: DATA EXTRACTIONSYSTEMATIC REVIEWS


Author

Total No. of Patients


11

Rahme et al14
SIS

Brox et al15

90

42

125

Placebo

Control/Comparison

SURGERY
Surgery (open or arthroscopic) vs. conservative treatment
Arthroscopic surgery
Conservative therapy (heat and
(n41)
cold packs, active training,
and strengthening exercise)
(n43)

Open surgery
(n21)

Conservative therapy (exercise


and education)
(n18)

Arthroscopic surgery
(n45)

Supervised exercise
(n50)

Outcome Measures

Mean change in Constant


score

3mo: WMD, 4.60 (95% CI, 12.48 to 3.28)


6mo: WMD, 1.40 (95% CI, 10.43 to 7.63)
12mo: WMD, 4.50 (95% CI, 13.73 to 4.73)

Mean PRIM score (12mo)


Constant score 80 (12mo)
Success (reduction of 100%
pain score from baseline)
Success and partial success
(reduction of 100% pain
score or reduction 51-99%
pain score from baseline)
Neer score

WMD, 0.0 (95% CI, 4.77 to 4.77)


RR1.05 (95% CI, 0.49 to 2.25)
6mo: RR1.07 (95% CI, 0.34 to 3.40)
12mo RR1.89 (95% CI, 0.81 to 4.41)
6 mo: RR 1.71 (95% CI, 0.81 to 3.63)
12 mo: RR 1.25 (95% CI, 0.80 to 1.93)

Sex-adjusted difference in
median Neer score
Husby et al17
SIS

39

44

SIS
Husby et al17
SIS

39

Open surgery
(n17)
(n18)
(n16)
(n19)

(n15)
(n14)

(n17)
(n18)

(n15)
(n15)
Arthroscopic surgery

(n16)
(n19)
Open surgery

(n19)
Arthroscopic surgery
(n15)

(n 22)
Open surgery
(n17)

Baseline: arthroscopic: 64 (median) vs


exercise: 67.5
3mo: arthroscopic: 84 vs exercise: 74
6mo: arthroscopic: 87 vs exercise: 86
3mo: 3.6 (95% CI, 0.2 to 7.4)
6mo: 2.0 (95 % CI, 1.4 to 5.4)

3mo: WMD, 1.00 (95% CI, 13.59 to 15.59)


6mo: WMD, 8.60 (95% CI, 17.40 to 0.20)
12mo: WMD, 2.70 (95% CI, 7.82 to 2.42)
96mo: not estimable
Mean pain during activity (VAS 3mo: WMD, 0.0 (95% CI, 19.77 to 19.77)
0100)
6mo: WMD, 12.00 (95% CI, 30.46 to 6.46)
12mo: WMD, 3.00 (95% CI, 20.67 to
14.67)
96mo: WMD, 0.0 (95% CI, 12.86 to 12.86)
Mean pain at rest
(VAS 0100)

Pain

Equivalent pain scores at 12, 26, and 52wk


(no data given)

Mean UCLA score

3mo: WMD, 0.0 (95% CI, 4.53 to 4.53)


6mo: WMD, 1.00 (95% CI, 3.96 to 5.96)

1907

Arch Phys Med Rehabil Vol 92, November 2011

Sachs et al19

Arthroscopic vs open surgery


Arthroscopic
(n15)
(n14)
(n15)
(n15)

Effect Size

SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME, Gebremariam

Coghlan et al
SIS
Haahr et al16
SIS

Treatment

1908

Total No. of Patients


17

Husby et al,
Tjonck et al18
Husby et al17
Iversen et al20
SIS

Spangehl et al21
SIS
Tjonck et al18
SIS
Tjonck et al18
SIS

Husby et al17
SIS

46

87
32 (36 shoulders)

32 (36 shoulders)

39

Treatment

Placebo

Control/Comparison

Outcome Measures

Effect Size

(n32)

(n31)

Mean UCLA score

12mo: WMD, 1.61 (95% CI, 1.22 to 4.44)

(n15)
Arthroscopic
(n21)

(n17)
Open surgery
(n20)

96mo: WMD, 0.0 (95% CI, 4.00 to 4.00)


WMD, 0.40 (95% CI, 3.43 to 4.14)
RR0.94 (95% CI, 0.65 to 1.35)

(n23)
(n27)

(n23)
(n24)

Arthroscopic

Open surgery

Mean UCLA score


Mean UCLA score
(FU time unclear) Good or
excellent
UCLA score
Good or excellent
UCLA score
Mean Constant score

(n17)
Arthroscopic
(n17)
(n17)
(n17)
(n17)
Arthroscopic
(n11)
(n14)

(n15)
Open surgery
(n15)
(n15)
(n15)
(n33)
Open surgery
(n13)
(n17)

(n13)

(n17)

(n13)

(n18)

(n11)

(n13)

(n14)
(n13)
(n13)

(n17)
(n17)
(n18)

(n11)

(n13)

(n14)

(n17)

(n13)

(n17)

(n13)

(n18)

(n11)

(n13)

Mean ROM: Active elevation


(12mo)
Abduction
External rotation (passive)
Internal rotation (passive)
Mean muscle strength:
external rotation at 60/s

Mean muscle strength:


external rotation at 180/s

Mean muscle strength: internal


rotation at 60/s

Mean muscle strength: internal


rotation at 180/s

(FU time unclear)


RR1.00 (95% CI, 0.68 to 1.48)
(FU time unclear)
WMD, 6.20 (95% CI, 6.14 to 18.54)

WMD, 2.20 (95% CI, 13.43 to 17.83)


WMD, 15.00 (95% CI, 2.68 to 32.68)
WMD, 10.70 (95% CI, 30.72 to 9.32)
WMD, 3.60 (95% CI, 5.71 to 12.91)
3mo: WMD, 7.00 (95% CI, 49.45 to
35.45)
6mo: WMD, 3.00 (95% CI, 45.00 to
39.00)
12mo: WMD, 15.00 (95% CI, 60.72 to
30.72)
96mo: WMD, 21.00 (95% CI, 19.06 to
61.06)
3mo: WMD, 3.00 (95% CI, 40.21 to
34.21)
6mo: WMD, 7.00 (95% CI, 25.40 to 39.40)
12mo: WMD, 0.0 (95% CI, 37.47 to 37.47)
96mo: WMD, 14.00 (95% CI, 24.94 to
24.94)
3mo: WMD, 16.00 (95% CI, 65.63 to
97.36)
6mo: WMD, 15.00 (95% CI, 52.74 to
82.74)
12mo: WMD, 10.00 (95% CI, 58.03 to
78.03)
96mo: WMD, 57.00 (95% CI, 14.28 to
128.28)
3mo: WMD, 1.00 (95% CI, 66.84 to
68.84)

SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME, Gebremariam

Arch Phys Med Rehabil Vol 92, November 2011

APPENDIX 2: DATA EXTRACTIONSYSTEMATIC REVIEWS (Contd)


Author

APPENDIX 2: DATA EXTRACTIONSYSTEMATIC REVIEWS (Contd)


Author

Total No. of Patients

Treatment

Placebo

Control/Comparison

(n17)

(n13)

(n17)

(n13)

(n18)

Arthroscopic surgery
(n19)

Open surgery
(n 22)

Outcome Measures

Sachs et al19
SIS

44

Ingvarrson et al22

20

Open surgical decompression: Neer vs modified Neer technique


Neer technique
Modified Neer technique
Mean degrees of movement
(8wk)

Rubenthaler et al23

38

Arthroscopic vs open removal of calcium deposit


Arthroscopic surgery
Open surgery
(n14)
(n19)

Calcific tendinitis

48 (49 shoulders)

Mean pain score (VAS)


(16mo)
Mean shoulder function (VAS)
(16mo)
Improvement: mean time of
physiotherapy (wk)
Holium-laser vs electrocautery in arthroscopic subacromial decompression
Arthroscopic acromioplasty
Mean UCLA score
Arthroscopic
using electrocautery
acromioplasty
using a Holium
laser
(n25)
(n24)
(n25)

(n24)

Mean ASES score

From baseline to 8-wk follow-up:


Flexion: Neer: 115 to 150 vs modified
Neer: 125 to 160
Extension: Neer: 40 to 50 vs modified
Neer: 40 to 55 Abduction: Neer: 105 to
145 vs modified Neer: 80 to 160
Exo-rotation: Neer: 45 to 60 vs modified
Neer: 50 to 65
Endo-rotation: Neer: 65 to 70 vs modified
Neer: 70 to 70
WMD, 0.30 (95% CI, 1.46 to 0.86)
WMD, 0.50 (95% CI, 2.08 to 1.08)
WMD, 5.00 (95% CI, 10.51 to 20.51)

3mo: WMD, 1.00 (95% CI, 2.99 to 0.99)

6mo: WMD, 1.00 (95% CI, 3.32 to 1.32)


12mo: WMD, 2.00 (95% CI 0.53 to 4.53)
3mo: WMD, 7.00 (95% CI, 8.85 to 14.85)
6mo: WMD, 8.00 (95% CI, 15.62 to
0.38) ifo electrocautery.
12mo: WMD, 3.00 (95% CI, 5.96 to 11.96)

Abbreviations: CI, confidence interval; FU, follow-up; ifo, in favor of; RR, relative risk; PRIM, aggregated pain and dysfunction score used in Project on Research and Intervention in
Monotonous work (range, 0 36); WMD, weighted mean difference; VAS, visual analog scale.

1909

Arch Phys Med Rehabil Vol 92, November 2011

(Murphy et al24)
SIS

Strength
Improvement (participant
evaluation, Moderate, or
complete improvement)

Effect Size

6mo: WMD, 21.00 (95% CI, 36.43 to


78.43)
12mo: WMD, 17.00 (95% CI, 42.17 to
76.17)
96mo: WMD, 45.00 (95% CI, 17.59 to
107.59)
No difference (no data given)
12mo: RR0.94 (95% CI, 0.78 to 1.12)

SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME, Gebremariam

(n14)

1910

Author

Treatment

Placebo

Control/Comparison

Outcome Measures and FU Time

ResultsStatistical
(P)

ResultsWords

SURGERY
Subacromial decompression vs radiofrequency-based plasma microtenotomy
Taverna et al25

ASD

Supraspinatus
tendinosis

(n30)

Everts et al26
SIS

PLG as add-on to OSD


PLG injection after OSD
(n20)

RF-based arthroscopic
microtenotomy
(n30)

OSD only
(n20)

VAS (range, 010) (baseline)

.470

Treatment vs comparison
Mean SD, 81 vs 81

ASES (range max100) (baseline)

.314

393 vs 394

UCLA (range max35) (baseline)


Constant score (range max100)
(baseline)
VAS (range, 010) (3mo, 6mo, 1y)

.510
.137

162 vs 172
514 vs 5111

.416

ASES (range max100) (3mo,


6mo, 1y)
UCLA (range max35) (3mo,
6mo, 1y)
Constant score (range max100)
(3mo, 6mo, 1y)

.964

The pain reduction profile was statistically


similar for both groups.
Improvement across time was statistically
similar for both groups.
Improvement across time was statistically
similar for both groups.
Improvement in scores across time were
statistically similar for both groups.

Pain (VAS) (6wk)


Use of pain medication (3mo)
Shoulder index score (calculated
from ADL score and VAS score)
(6wk)
Instability score (selfassessment) (VAS)
(6wk)
ADL (questionnaire) (6wk)
ROM
(12wk)

.794
.978

.001
no P given
.001

NS
.13
.05
.001
p0.05

PLG vs control, decrease in pain ifo PLG


(no exact data given)
PLG used less pain medication than
control (no exact data given)
Sig. better results ifo patients with PLG
(no exact data given)
Preoperative: PLG: mean SD, 3.32.7 vs
control: 3.72.9
6wk: PLG: 1.10.3 vs control: 2.02.0
more activities ifo PLG (no exact data
given)
2wk: Sig. improvement ifo PLG
6 and 12wk: Sig. improvement ifo PLG

Abbreviations: ADL, activities of daily living; ASD, arthroscopic subacromial decompression; FU, follow-up; ifo, in favor of; RF, radiofrequency; max, maximum; NS, not significant; Sig.,
significant; VAS, visual analog scale (range, 0 10).

SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME, Gebremariam

Arch Phys Med Rehabil Vol 92, November 2011

APPENDIX 3: DATA EXTRACTIONRECENT RCTS

APPENDIX 4: DATA EXTRACTIONADDITIONAL RCTS


Author

Hultenheim
Klintberg et al27

POSTSURGERY
PG (active-assisted
ROM exercises on day 1 of
surgery (3/d) and
strengthening exercises after
6wk

Placebo

Control/Comparison

TG
(active- assisted dynamic
exercises for rotator
cuff after 6wk (3/d)
and strengthening
exercises after 8wk
post operative

(3/d)(n13)

Outcome Measures and FU


Time

Pain during activity


(VAS)

ResultsStatistical
(P)

NS

(24mo)

No P given
No P given
No P given
No P given

Pain during rest


(VAS)
(24mo)

NS
No P given
No P given
No P given

ROM: (degrees)

NS

Flexion:

.05
No P given
No P given
No P given

(n20)

Extension

(097)
3mo: 5 (078) vs 20 (075)
6mo: 14 (070) vs 12 (070)
12mo: 2 (035) vs 23 (084)
PG vs TG, median (range)
Baseline: 30 (972) vs 50 (095)
3mo: 0 (063) vs 10 (082)
6mo: 1 (063) vs 0 (030)
12mo: 0 (033) vs 5 (046)
PG vs TG, median (range)
Baseline: 150 (95170) vs 145 (90
180)
6wk: 160 (120180) vs 140 (85170)
3mo: 160 (140165) vs 150 (90170)
6mo: 165 (110180) vs 150 (85180)
12mo: 160 (140180) vs 150 (130180)
PG vs TG, median (range)
Baseline: 40 (2555) vs 40 (1575)

NS

3mo: 50 (4060) vs 40 (2070) ifo PG


6mo: 50 (3070) vs 40 (2070)
12mo: 50 (3560) vs 40 (3065)
PG vs TG, median (range)
Baseline: 170 (50180) vs 150 (25
180)
3mo: 180 (170180) vs 160 (70180)
ifo PG
6mo: 180 (90180) vs 170 (85180)
12mo: 180 (130180) vs 170 (80180)
ifo PG
PG vs TG, median (range)

(no P given)
.05
No P given
No P given
No P given

Baseline: 57 (4089) vs 46 (1778)


6wk: 67 (3496) vs 48 (1878), ifo PG
3mo: 80 (6088) vs 59 (1994)
6mo: 84 (3594) vs 72 (3097)
12mo: 87 (6396) vs 69 (2297)

.05
No P given
.05
Shoulder function:
Constant score
(24mo)

PG vs TG, median (range)


Baseline: 72 (30100) vs 67

1911

Arch Phys Med Rehabil Vol 92, November 2011

Abduction

NS
No P given
.05
No P given
No P given
NS
No P given

ResultsWords

SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME, Gebremariam

SIS

Treatment

1912

Author

Hoe-Hansen et al28
SIS

Treatment

ASD plus ketoprofen 200mg


1/d for 6wk
(n21)

Placebo

Control/Comparison

Outcome Measures and FU


Time

No. of patients showing


mild or no pain

ASD
plus
placebo
(n20)

Mean UCLA score

ResultsStatistical
(P)

Treatment vs placebo:
6wk: 16/19 vs 9/19

NS
(No P given)
.05

2y: 14/17 vs 10/15

NS

Active forward flexion


(degrees)

Active abduction
(degrees)

(No P given)
.05

NS
(No P given)
.05

NS
(No P given)
Jarvela et al29
SIS

Study group: pain pump with


0.375% ropivacaine infusion
at continuous rate of 5mL/h
in the subacromial space
plus rehabilitation (ie, a
sling for the first night, free
ROM on first day after
surgery and physiotherapy)
(n25)

Control group only


rehabilitation (n25)

UCLA score
(2y)
Constant score
(2y)

ResultsWords

.05

.137
.845
.831
.243

Treatment: mean (range), 16 (827) at


baseline to 30 (1635) at 6-wk FU
vs placebo:
16 (1922) at baseline to 26 (1635) at
6-wk FU
At 2-y FU: Treatment: 31 (1735) vs
placebo 29 (1635)
Treatment: 145 (80180) at baseline
to 173 (90180) at 6-wk
FU vs placebo: 149 (70180) to 169
(90180) at 6-wk FU.
At 2-y FU: data not given
Treatment: 124 (50180) at baseline
to 169 (90180) at 6-wk
FU vs placebo: 128 (45180) at
baseline to 165 (70180) at 6-wk FU
At 2-y FU: data not given
Study group vs control group
(Mean SD)
Baseline: 203 vs 184
2y: 333 vs 334
Study group vs. control group
(Mean SD)
Baseline: 6010 vs 6011 2 years:
948 vs 965

Abbreviations: FU, follow-up; ifo, in favor of; NS, not significant; PG, progressive group; TG, traditional group; VAS, visual analog scale (range, 0 10).

SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME, Gebremariam

Arch Phys Med Rehabil Vol 92, November 2011

APPENDIX 4: DATA EXTRACTIONADDITIONAL RCTS (Contd)

SURGICAL TREATMENT SUBACROMIAL IMPINGEMENT SYNDROME, Gebremariam

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Arch Phys Med Rehabil Vol 92, November 2011