Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis

Abstract

Many treatments for shoulder impingement syndrome (SIS) are available in clinical practice; some of which have already been compared with other treatments by various investigators. However, a comprehensive treatment comparison is lacking. Several widely used electronic databases were searched for eligible studies. The outcome measurements were the pain score and the Constant-Murley score (CMS). Direct comparisons were performed using the conventional pair-wise meta-analysis method, while a network meta-analysis based on the Bayesian model was used to calculate the results of all potentially possible comparisons and rank probabilities. Included in the meta-analysis procedure were 33 randomized controlled trials involving 2300 patients. Good agreement was demonstrated between the results of the pair-wise meta-analyses and the network meta-analyses. Regarding nonoperative treatments, with respect to the pain score, combined treatments composed of exercise and other therapies tended to yield better effects than single-intervention therapies. Localized drug injections that were combined with exercise showed better treatment effects than any other treatments, whereas worse effects were observed when such injections were used alone. Regarding the CMS, most combined treatments based on exercise also demonstrated better effects than exercise alone. Regarding surgical treatments, according to the pain score and the CMS, arthroscopic subacromial decompression (ASD) together with treatments derived from it, such as ASD combined with radiofrequency and arthroscopic bursectomy, showed better effects than open subacromial decompression (OSD) and OSD combined with the injection of platelet-leukocyte gel. Exercise therapy also demonstrated good performance. Results for inconsistency, sensitivity analysis, and meta-regression all supported the robustness and reliability of these network meta-analyses. Exercise and other exercise-based therapies, such as kinesio taping, specific exercises, and acupuncture, are ideal treatments for patients at an early stage of SIS. However, low-level laser therapy and the localized injection of nonsteroidal anti-inflammatory drugs are not recommended. For patients who have a long-term disease course, operative treatments may be considered, with standard ASD surgery preferred over arthroscopic bursectomy and the open surgical technique for subacromial decompression. Notwithstanding, the choice of surgery should be made cautiously because similar outcomes may also be achieved by the implementation of exercise therapy.

FIGURE 1

PRISMA 2009 flow diagram.

FIGURE 2

(A) Risk of bias graph. (B) Risk of bias summary.

FIGURE 3

(A) Network 1: Nonoperative treatments (pain score). (B) Network 2: Nonoperative treatments (CMS). (C) Network 3: Operative treatments (pain score). (D) Network 4: Operative treatments (CMS). Note: the size of the circle represents the number of patients; the thickness of the edge represents the number of studies. ACU = acupuncture therapy, ASD = routine arthroscopic subacromial decompression, COR = corticosteroid injection, DF = diacutaneous fibrolysis therapy, EXE = routine exercise treatment, KT = kinesio taping therapy, LLLT = low-level laser therapy, NSAID = nonsteroidal anti-inflammatory drug injection, OSD = open subacromial decompression, PEMF = pulsed electromagnetic field therapy, PLG = platelet-leukocyte gel injection, RF = radiofrequency therapy, SE = specific exercise therapy, US = ultrasound therapy.

FIGURE 4

(A) Treatments compared with EXE (pain score). (B) Treatments compared with EXE (CMS). ACU = acupuncture therapy, COR = corticosteroid injection, DF = diacutaneous fibrolysis therapy, EXE = routine exercise treatment, HYA = hyaluronate injection, KT = kinesio taping therapy, LLLT = low-level laser therapy, MAN = manual therapy, MWD = microwave diathermy therapy, NON = no treatment/placebo, NSAID = nonsteroidal anti-inflammatory drug injection, PEMF = pulsed electromagnetic field therapy, rESWT = radial extracorporeal shockwave therapy, SE = specific exercise therapy, US = ultrasound therapy.

FIGURE 5

(A) Rank probability of nonoperative treatments (pain score). (B) Rank probability of nonoperative treatments (CMS). (C) Rank probability of operative treatments (pain score). (D) Rank probability of operative treatments (CMS). Note: 1. Different gray scales represent different ranks, with rank 1 representing the best and rank n representing the worst. 2. Each treatment has a sum of 1.0 for all its possible rank probabilities. 3. The darkness of each bar represents the effectiveness of the corresponding treatment, with darker shades signifying better effectiveness. ACU = acupuncture therapy, ASD = routine arthroscopic subacromial decompression, COR = corticosteroid injection, DF = diacutaneous fibrolysis therapy, EXE = routine exercise treatment, HYA = hyaluronate injection, KT = kinesio taping therapy, LLLT = low-level laser therapy, MAN = manual therapy, MWD = microwave diathermy therapy, NON = no treatment/placebo, NSAID = nonsteroidal anti-inflammatory drug injection, onlyBUR = arthroscopic bursectomy without acromioplasty, OSD = open subacromial decompression, PEMF = pulsed electromagnetic field therapy, PLG = platelet-leukocyte gel injection, rESWT = radial extracorporeal shockwave therapy, RF = radiofrequency therapy, SE = specific exercise therapy, US = ultrasound therapy.

FIGURE 6

(A) SUCRA for nonoperative treatments (pain score). (B) SUCRA for nonoperative treatments (CMS). (C) SUCRA for operative treatments (pain score). (D) SUCRA for operative treatments (CMS). Note: The area under the curve represents the cumulative rank probability of each treatment, with larger areas signifying higher probabilities. ACU = acupuncture therapy, ASD = routine arthroscopic subacromial decompression, COR = corticosteroid injection, DF = diacutaneous fibrolysis therapy, EXE = routine exercise treatment, HYA = hyaluronate injection, KT = kinesio taping therapy, LLLT = low-level laser therapy, MAN = manual therapy, MWD = microwave diathermy therapy, NON = no treatment/placebo, NSAID = nonsteroidal anti-inflammatory drug injection, onlyBUR = arthroscopic bursectomy without acromioplasty, OSD = open subacromial decompression, PEMF = pulsed electromagnetic field therapy, PLG = platelet-leukocyte gel injection, rESWT = radial extracorporeal shockwave therapy, RF = radiofrequency therapy, SE = specific exercise therapy, US = ultrasound therapy.

FIGURE 6 (Continued)

(A) SUCRA for nonoperative treatments (pain score). (B) SUCRA for nonoperative treatments (CMS). (C) SUCRA for operative treatments (pain score). (D) SUCRA for operative treatments (CMS). Note: The area under the curve represents the cumulative rank probability of each treatment, with larger areas signifying higher probabilities. ACU = acupuncture therapy, ASD = routine arthroscopic subacromial decompression, COR = corticosteroid injection, DF = diacutaneous fibrolysis therapy, EXE = routine exercise treatment, HYA = hyaluronate injection, KT = kinesio taping therapy, LLLT = low-level laser therapy, MAN = manual therapy, MWD = microwave diathermy therapy, NON = no treatment/placebo, NSAID = nonsteroidal anti-inflammatory drug injection, onlyBUR = arthroscopic bursectomy without acromioplasty, OSD = open subacromial decompression, PEMF = pulsed electromagnetic field therapy, PLG = platelet-leukocyte gel injection, rESWT = radial extracorporeal shockwave therapy, RF = radiofrequency therapy, SE = specific exercise therapy, US = ultrasound therapy.

FIGURE 6 (Continued)

(A) SUCRA for nonoperative treatments (pain score). (B) SUCRA for nonoperative treatments (CMS). (C) SUCRA for operative treatments (pain score). (D) SUCRA for operative treatments (CMS). Note: The area under the curve represents the cumulative rank probability of each treatment, with larger areas signifying higher probabilities. ACU = acupuncture therapy, ASD = routine arthroscopic subacromial decompression, COR = corticosteroid injection, DF = diacutaneous fibrolysis therapy, EXE = routine exercise treatment, HYA = hyaluronate injection, KT = kinesio taping therapy, LLLT = low-level laser therapy, MAN = manual therapy, MWD = microwave diathermy therapy, NON = no treatment/placebo, NSAID = nonsteroidal anti-inflammatory drug injection, onlyBUR = arthroscopic bursectomy without acromioplasty, OSD = open subacromial decompression, PEMF = pulsed electromagnetic field therapy, PLG = platelet-leukocyte gel injection, rESWT = radial extracorporeal shockwave therapy, RF = radiofrequency therapy, SE = specific exercise therapy, US = ultrasound therapy.