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Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for shoulder pain |
Philadelphia Panel |
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Authors' objectives To determine the effectiveness of rehabilitation for shoulder pain, to develop evidence-based clinical practice guidelines.
Searching MEDLINE (from 1962 to 2000), EMBASE (from 1988 to 2000), CINAHL (from 1982 to 2000), HealthSTAR (from 1975 to 2000) and the Cochrane Controlled Trials Register (2000) were searched for studies published in English, French, or Spanish. The registers of the Cochrane Rehabilitation and Related Therapies Field and the Cochrane Musculoskeletal Group, and PEDro were also searched. Additional studies were sought from the reference lists of all included studies and through contact with experts.
Study selection Study designs of evaluations included in the reviewRandomised controlled trials (RCTs), controlled clinical trials (CCTs), cohort and case-control studies were eligible for inclusion. Case series and uncontrolled cohort studies were excluded.
Specific interventions included in the reviewStudies of therapeutic exercise, massage, transcutaneous electrical nerve stimulation (TENS), thermotherapy (hot or cold packs), ultrasound, electrical stimulation, and combinations of these interventions were eligible for inclusion. Studies of iontophoresis, surgery, electroanalgesia, in-patient interventions and educational interventions were excluded.
Participants included in the reviewStudies of participants with shoulder pain were eligible for inclusion. Shoulder pain was defined as non-specific shoulder pain, calcific tendonitis, bursitis and capsulitis. Studies of rheumatoid arthritis and osteoporotic shoulder pain were excluded from the review. Further details on the type of shoulder pain, duration of symptoms and age of the participants were given in the report.
Outcomes assessed in the reviewStudies evaluating pain, functional status, strength, range of motion, return to work, patient satisfaction, activities of daily living, or quality of life were eligible for inclusion. Studies evaluating psychological or physiological outcomes, cardiopulmonary function and postural assessment were excluded.
How were decisions on the relevance of primary studies made?Two reviewers independently assessed the articles for inclusion.
Assessment of study quality Each study was assigned a quality score from 1 (lowest) to 5 (highest) using the Jadad instrument to assess randomisation, blinding and withdrawals. Two reviewers independently assessed the validity of each included study. Any disagreements were resolved by discussion with a third reviewer.
Data extraction Two reviewers independently extracted the data from each included study. Any disagreements were resolved by discussion with a third reviewer. Data were extracted from each included study to allow an assessment of clinical relevance and statistical significance.
To determine clinical relevance, data were extracted on the change from baseline for the intervention and control groups, to derive a percentage relative difference. A relative difference of 15% or greater between the intervention and control groups was assumed to be clinically important.
To determine the statistical significance of continuous outcomes, data were extracted on the mean and standard deviation and used to derive a weighted mean difference (WMD) or standardise mean difference (SMD), as appropriate, for each individual outcome. For binary outcomes, data on the occurrence of an event were extracted from the individual studies and used to calculate a relative risk (RR).
Methods of synthesis How were the studies combined?The studies were grouped according to the intervention, type of shoulder pain and level of evidence. To determine statistical significance, the results from individual studies were combined using fixed- or random-effects meta-analysis. Pooled WMD, SMD or RR, along with 95% confidence intervals, were calculated separately for each type of shoulder pain where sufficient data were available. To determine clinical importance, the results of the absolute benefit and percentage relative difference for each included study were tabulated and discussed narratively.
How were differences between studies investigated?Statistical tests for homogeneity were performed using the Cochran Q-test. Differences in clinical importance were assessed through a comparison of the tabulated results.
Results of the review The authors stated that 23 studies met the inclusion criteria and 12 were subsequently excluded because of irrelevant outcomes or an inappropriate control group. However, only 9 studies were detailed in the text and tables. In addition, there were discrepancies between the sample sizes of the included studies as detailed in the text and table. This abstract will be based on the tabulated details.
Six RCTs (n=438) and 3 (n=79) were tabulated and included in the analysis. Further details of the studies that met the inclusion criteria, but were excluded from the review, were given.
Two studies obtained a quality score of 5, two scored 4, two scored 2, two scored 1 and one scored zero.
Calcific shoulder tendonitis (1 RCT, n=61).
At 2 months, therapeutic ultrasound was associated with a statistically significant reduction in pain, (absolute benefit was 4.8, corresponding to a 77% relative difference; P<0.05), an improvement in functional status (absolute benefit was 2.2, corresponding to a 15% relative difference; P<0.05) and improvement in quality of life (absolute benefit was 1.6, corresponding to a 25% relative difference; P<0.05) compared with placebo. No statistically significant difference was found at 9 months.
Non-specific shoulder pain.
Ultrasound (4 RCTs, n=297; 3 CCTs, n=79).
No statistically significant difference was found in pain or functional ability between continuous therapeutic ultrasound and placebo (2 RCTs, n=44), or pulsed therapeutic ultrasound and placebo (2 RCTs, n=253). Similarly, no statistically significant difference was found in pain, patient global assessment, or functional ability (2 CCTs, n=50). One further CCT (n=29) found a 37% relative difference in pain between placebo and therapeutic ultrasound. However, this was not statistically significant (P-value not given).
Therapeutic exercise (1 RCT, n=80).
Exercise was associated with improved functional ability and reduced pain compared with a detuned laser. However, there were insufficient data to determine clinical relevance or statistical significance.
Authors' conclusions The evidence supports the use of therapeutic ultrasound for the treatment of calcified shoulder tendonitis. Further research is required to determine the effectiveness of therapeutic exercise, thermotherapy, massage, electromyographic feedback, TENS, electrical stimulation and combined rehabilitation for patients with non-specific shoulder pain.
CRD commentary The review addressed a clear question and the inclusion criteria appear appropriate. Several sources were used to identify relevant studies and attempts were made to limit language and publication bias. Methods were used to minimise bias in the study selection and data extraction processes. The validity of the included studies was assessed systematically, although it was not used to explore whether the treatment effect differed according to study quality. Additional methodological information was provided in a separate report (see Other Publications of Related Interest).
Details of each included study were given in the report and the methods used to analyse the data appear to have been appropriate. However, discrepancies in the reporting of information in the text and table mean it is difficult to ascertain the accuracy of the results presented. Overall, this was a well-conducted review, although there was poor attention to detail in the reporting of the results. The authors' conclusion that therapeutic ultrasound should be recommended for the treatment of calcified shoulder was based on a single study with a small sample size. Therefore, additional studies would be required to support this evidence. The authors' call for further research into the use of rehabilitation interventions for shoulder pain is appropriate.
Implications of the review for practice and research Practice: The authors stated that therapeutic ultrasound can provide clinically important short-term pain relief to patients with calcific tendonitis. However, given the evidence presented in the review, further studies are needed to support this recommendation.
Research: The authors stated that well-designed RCTs are needed to determine the effectiveness of therapeutic exercise, thermotherapy, massage, electromyographic feedback, TENS, electrical stimulation and combined rehabilitation for patients with non-specific shoulder pain.
Funding Cigna Foundation; the Ministry of Human Resources and Development, Government of Canada (Summer Students Program); Ontario Ministry of Health and Long-Term Care.
Bibliographic details Philadelphia Panel. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for shoulder pain. Physical Therapy 2001; 81(10): 1719-1730 Other publications of related interest Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions: overview and methodology. Phys Ther 2001;81:1629-40.
Indexing Status Subject indexing assigned by NLM MeSH Calcinosis /complications /rehabilitation; Evidence-Based Medicine; Humans; Physical Therapy Modalities /standards; Shoulder Pain /etiology /rehabilitation; Tendinopathy /complications /rehabilitation AccessionNumber 12001002438 Date bibliographic record published 28/02/2005 Date abstract record published 28/02/2005 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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