Question: In patients who have shoulder pain with subacromial
impingement, is arthroscopic subacromial decompression more effective than
graded physiotherapy?
Design: Randomized (allocation
concealed)*,
unblinded, controlled trial with 1-year follow-up.
Information provided by author.
Setting: A hospital in Ringkjoebing County, Denmark.
Patients: Studied were 90 patients who were from 18 to 55 years of
age; had had symptoms for 6 months to 3 years; and met the following
diagnostic criteria: presence of shoulder pain, pain on abduction of the
shoulder with painful arch, a positive impingement sign (Hawkins sign), and a
positive impingement test (relief of pain after injection of local anesthetic
into the subacromial space). Follow-up was 93% (mean age, 44 y; 69%
women).
Intervention: Patients were allocated to physiotherapy with training
(n = 43) or arthroscopic surgery (n = 41). Two experienced physiotherapists
provided 19 sessions of physiotherapy (up to 60 minutes each) for 12 weeks.
Heat, cold packs, or soft-tissue treatments were first applied. Patients then
had active training of the periscapular muscles and strengthening of the
stabilizing muscles of the shoulder joint. Training sessions were held 3 times
weekly during weeks 1 to 2, twice weekly during weeks 3 to 5, and once weekly
during weeks 6 to 12. Patients were encouraged to do the exercises at home
daily. After 12 weeks, patients were instructed to do home exercises 2 to 3
times each week. Patients in the surgery group had an investigation for
stability of the shoulder joint under general anesthesia followed by
arthroscopic examination of the glenohumeral joint, the rotator cuff, and the
subacromial bursa. Two experienced surgeons did bursectomy with partial
resection of the anteroinferior part of the acromion and coracoacromial
ligament.
Main outcome measures: The main outcome was change in Constant score
(combined measure of 4 subscores: pain, function, range of movements, and
force). The secondary outcome was pain and dysfunction as assessed with use of
the PRIM (Project on Research and Intervention in Monotonous work) aggregated
pain and dysfunction scoring system.
Main results: Analysis was by intention to treat. Groups did not
differ for any outcome
(Table).
Conclusion: In patients who have shoulder pain with subacromial
impingement, arthroscopic subacromial decompression and graded physiotherapy
had similar effectiveness.
Studies on subacromial impingement are notoriously difficult to interpret
given that impingement is a clinical diagnosis based on history and
examination that is known to vary among clinicians. Moreover, many clinicians
believe that surgical decompression is overused. Consequently, the study by
Haahr and colleagues provides helpful new information relevant to the
treatment of shoulder pain. The finding that the outcome after arthroscopic
surgical decompression was no better than that after 12 weeks of physiotherapy
suggests that caution should be exercised in selecting patients for
surgery.
However, several methodological issues must be considered. First, few
clinicians would perform surgery in patients as young as 18 years of age, as
was done in this study, given that instability is the far more likely
diagnosis. Second, examination under anesthesia was performed on surgical
patients, but it is unclear how these findings affected patient inclusion.
Third, while patients with "signs of a rupture of the cuff" were
excluded, no information was given regarding their radiographic findings.
Finally, of greatest concern, the therapists who guided nonoperative care
performed the outcome examinations. Because we would question any operative
study in which the surgeon performed the outcome examinations, the same
criterion should apply to nonoperative treatments.
In essence, this study proves that impingement generally improves with
nonoperative management. Consequently, in the absence of acute trauma or
sudden weakness, we recommend 3 to 6 months of physiotherapy before
arthroscopy. The key question remains: how much physiotherapy is enough?
Research has shown that those with acute symptoms do better with physiotherapy
than do those with chronic
symptoms1. Solving
this dilemma will require more research to differentiate which
criteria—such as stratification by age—can be used to separate the
patients who will improve with physiotherapy from those who require
surgery.
Morrison DS, Frogameni AD, Woodworth P.
Nonoperative treatment of subacromial impingement syndrome. J Bone
Joint Surg Am.1997;79:
732-7.79732
1997
[PubMed]