Review
Conservative or surgical treatment for subacromial impingement syndrome? A systematic review

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Background

Patients with subacromial impingement syndrome are often operated on when conservative treatments fail. But does surgery really lead to better results than nonoperative measures? This systematic review compared effects of conservative and surgical treatment for subacromial impingement syndrome in terms of improvement of shoulder function and reduction of pain.

Methods

A literature search for randomized controlled trials (RCTs) in PubMed, EMBASE, PEDro, and the Cochrane Central Register of Controlled Trials was conducted. Two reviewers assessed the methodological quality of the selected studies. A best-evidence synthesis was used to summarize the results.

Results

Four RCTs were included in this review. Two RCTs had a medium methodological quality, and 2 RCTS had a low methodological quality. No differences in outcome between the treatment groups were reported for any of the studies, irrespective of quality.

Conclusion

No high-quality RCTs are available so far to provide possible evidence for differences in outcome; therefore, no confident conclusion can be made. According to the best-evidence synthesis, however, there is no evidence from the available RCTs for differences in outcome in pain and shoulder function between conservatively and surgically treated patients with SIS.

Level of evidence

Review.

Section snippets

Literature search

A search of the literature in PubMed (from 1948 onward), EMBASE (from 1947 onward), PEDro (from 1929 onward), and the Cochrane Central Register of Controlled Trials was conducted to identify relevant publications until October 2007, without language restrictions. The literature search strategy for PubMed is presented in Table I. Reference lists of retrieved articles and articles on surgical interventions for SIS were screened for additional publications. Names of first authors of selected

Study selection

The PubMed search resulted in 162 citations (Table I). One more citation was found in the Cochrane Register. No other studies were identified through the EMBASE or PEDro databases by hand search or citation tracking. The title or abstract, or both, was used to exclude 155 articles (Figure 1), and 8 were retrieved for a more detailed evaluation. Next, 2 RCTs were excluded for reasons of poster presentation and commentary. Six articles describing 4 RCTs met our inclusion criteria.7, 8, 19, 20, 31

Discussion

Failed conservative treatment of SIS is often followed by surgery. This systematic review was designed to determine if the results of surgery for SIS are better than those of conservative treatment in terms of improvement of shoulder function and reduction of pain.

Recommendations

To answer the question of whether surgery for SIS is indeed more effective than conservative treatment, high-quality trials are needed. These trials should use outcome measures that quantify improvement of shoulder function and reduction of pain that are valid, reliable, and responsive in these study populations. Correct tests, such as the impingement test, should be used to diagnose patients with SIS, and strict inclusion and exclusion criteria should be observed to create homogenous study

Acknowledgments

This study was supported by a grant from University Medical Center Groningen, The Netherlands. We thank Truus van Ittersum for her help in developing search strategies for the electronic databases used. We are also grateful to Daniëlle van der Windt for her comments. This study is supported by a grant from University Medical Center Groningen, The Netherlands.

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