Comparative effectiveness of treatment options for subacromial shoulder conditions: a systematic review and network meta-analysis

Abstract

Background: There are currently many treatment options for patients with subacromial shoulder conditions (SSCs). Clinical decision-making regarding the best treatment option is often difficult. This study aims to evaluate the comparative effectiveness of treatment options for relieving pain and improving function in patients with SSCs. Methods: Eight databases [including MEDLINE, Embase, CINAHL, AMED, PEDro, Cochrane Database of Systematic Reviews and World Health Organization (WHO) International Clinical Trials Registry] were searched from inception until April 2020. Randomised clinical/controlled trials of adult patients investigating the effects of nonsurgical (e.g. corticosteroid injections, therapeutic exercise, shockwave therapy) and surgical treatment for SSCs, compared with each other, placebo, usual care or no treatment, were retrieved. Pairs of reviewers screened studies independently, quality appraised eligible studies using the Cochrane risk of bias tool, extracted and checked data for accuracy. Primary outcomes were pain and disability in the short term (⩽3 months) and long term (⩾6 months). Direct and indirect evidence of treatment effectiveness was synthesised using random-effects network meta-analysis. Results: The review identified 177 eligible trials. Summary estimates (based on 99 trials providing suitable data, 6764 patients, 20 treatment options) showed small to moderate effects for several treatments, but no significant differences on pain or function between many active treatment comparisons. The primary analysis indicated that exercise and laser therapy may provide comparative benefit in terms of both pain and function at different follow-up time-points, with larger effects found for laser in the short term at 2–6 weeks, although direct evidence was provided by one trial only, and for exercise in the longer term [standardised mean difference (SMD) 0.39, 95% confidence interval (CI) 0.18, 0.59 at 3–6 months] compared with control. Sensitivity analyses excluding studies at increased risk of bias confirmed only the comparative effects of exercise as being robust for both pain and function up until 3-month follow-up. Conclusion: Current evidence shows small to moderate effect sizes for most treatment options for SSCs. Six treatments had a high probability of being most effective, in the short term, for pain and function [acupuncture, manual therapy, exercise, exercise plus manual therapy, laser therapy and Microcurrent (MENS) (TENS)], but with low certainty for most treatment options. After accounting for risk of bias, there is evidence of moderate certainty for the comparative effects of exercise on function in patients with SSCs. Future large, high-quality pragmatic randomised trials or meta-analyses are needed to better understand whether specific subgroups of patients respond better to some treatments than others.

Patient education on subacromial impingement syndrome

“…Since there is no evaluation tool for the quality assessment on information specif-ically for SAIS, the authors created a novel scoring system (referred to as the subacromial impingement syndrome score, SAISS) based on a literature review and expert opinion [22][23][24][25][26][27]. Comparable approaches were used to create scoring systems in previous studies [11,28,29].…”

Tailored exercise and manual therapy versus standardised exercise for patients with shoulder subacromial pain: a feasibility randomised controlled trial (the Otago MASTER trial)

“…However, the strength of evidence supporting this recommendation is limited and findings from two large trials found exercise therapy did not provide additional benefit over usual care 9 10. On the other hand, a recent systematic review and network meta-analysis suggested that, among other interventions, exercise and manual therapy are likely to be effective in the short term for pain and function outcomes 11. Currently, it is uncertain: (1) if exercise therapy is more effective than placebo; (2) which form of exercise therapy is likely to be more effective; (3) whether exercise combined with manual therapy is likely to be more effective than exercise alone.…”

“…The role of manual therapy in the management of patients with shoulder subacromial pain is unclear and debated in the literature 17. There are conflicting recommendations from previous trials and reviews in the topic 11 14 17 18. Evidence from trials on other musculoskeletal disorders suggests that including manual therapy led to better clinical outcomes when compared with corticosteroid injection or wait-and-see in the management of other musculoskeletal disorders (eg, tennis elbow),19 or usual care when managing patients with hip or knee osteoarthritis 20.…”

“… 17 There are conflicting recommendations from previous trials and reviews in the topic. 11 14 17 18 Evidence from trials on other musculoskeletal disorders suggests that including manual therapy led to better clinical outcomes when compared with corticosteroid injection or wait-and-see in the management of other musculoskeletal disorders (eg, tennis elbow), 19 or usual care when managing patients with hip or knee osteoarthritis. 20 A recent systematic review and network meta-analyses suggested exercise and manual therapy are likely to have small to moderate treatment effects on patients with shoulder subacromial pain, but the level of certainty was low.…”

“… 20 A recent systematic review and network meta-analyses suggested exercise and manual therapy are likely to have small to moderate treatment effects on patients with shoulder subacromial pain, but the level of certainty was low. 11 …”