What is the best treatment for shoulder pain?

Both manual physical therapy (MPT) and corticosteroid injections (CSI) significantly improve symptoms in patients with shoulder impingement syndrome (SIS), but physical therapy may be less costly to the healthcare system, according to a new study.

Objective: To compare the effectiveness of 2 common nonsurgical treatments for SIS.

Design: Randomized, single-blind, comparative-effectiveness, parallel-group trial. (ClinicalTrials.gov: NCT01190891)

Setting: Military hospital–based outpatient clinic in the United States.

Patients: 104 patients aged 18 to 65 years with unilateral SIS between June 2010 and March 2012.

Intervention: Researchers randomly assigned consecutive patients aged 18 to 65 years with unilateral shoulder pain to receive CSI or MPT. Patients were referred from family practice and orthopedic clinics. None had had physical therapy or corticosteroid injections within the previous 3 months.

 The CSI group received up to 3 injections of 40 mg triamcinolone acetonide 1 month apart. The injections were administered by a family practice physician with sports medicine fellowship training.
Matched to individual impairment, the MPT intervention consisted of a combination of joint and soft-tissue mobilizations, manual stretches, contract-relax techniques, and reinforcing exercises directed to the shoulder girdle or thoracic or cervical spine. Patients were treated twice weekly over a 3-week period and prescribed home exercises.
 Ten CSI patients crossed over to receive physical therapy, and 9 in the MPT group crossed over to receive injections.

Measurements: The primary outcome was change in Shoulder Pain and Disability Index scores at 1 year. Secondary outcomes included the Global Rating of Change scores, the Numeric Pain Rating Scale scores, and 1-year health care use.

Results: After 1 year, both the CSI group (n = 52) and the MPT group (n = 46) had a greater than 50% improvement in the Shoulder Pain and Disability Index (SPADI), with neither group being superior. The between-group difference in the SPADI, a 13-item, self-administered questionnaire that includes pain and disability subscales, was 1.55% (95% confidence interval [CI], –6.3% to 9.4%; P = .70). The minimal clinically important difference for the SPADI is a change between 8 and 13 points (6% to 10%).

Ratings on the Global Rating of Change (GRC) scale improved by 3 points (95% CI, 2 - 4) for each group. The GRC measures overall perceived changes in quality of life, with a score of 3 or more points being clinically meaningful.
Self-reported pain intensity as measured by the 11-point Numeric Pain Rating Scale significantly improved from baseline (P < .05) in both groups, but neither intervention was superior (between-group difference 0.4 (95% CI, –0.5 to 1.2; P = .42).

During the 1-year follow-up, patients receiving CSI had more SIS-related visits to their primary care provider (60% vs. 37%) and required additional steroid injections (38% vs. 20%), and 19% needed physical therapy. Transient pain from the CSI was the only adverse event reported.

Conclusion: Both groups experienced significant improvement. The manual physical therapy group used less 1-year SIS-related health care resources than the CSI group.

Rhon DI, Boyles RB, Cleland JA. One-Year Outcome of Subacromial Corticosteroid Injection Compared With Manual Physical Therapy for the Management of the Unilateral Shoulder Impingement Syndrome: A Pragmatic Randomized Trial. Ann Intern Med. doi online 5.8.2014

Errors of level in spinal surgery

Wrong-level surgery is a unique pitfall in spinal surgery and is part of the wider field of wrong-site surgery. Wrong-site surgery affects both patients and surgeons and has received much media attention. 

METHODS:We performed this systematic review to determine the incidence and prevalence of wrong-level procedures in spinal surgery and to identify effective prevention strategies. We retrieved 12 studies reporting the incidence or prevalence of wrong-site surgery and that provided information about prevention strategies. Of these, ten studies were performed on patients undergoing lumbar spine surgery and two on patients undergoing lumbar, thoracic or cervical spine procedures. 

RESULTS:A higher frequency of wrong-level surgery in lumbar procedures than in cervical procedures was found. Only one study assessed preventative strategies for wrong-site surgery, demonstrating that current site-verification protocols did not prevent about one-third of the cases. 

CONCLUSION: The current literature does not provide a definitive estimate of the occurrence of wrong-site spinal surgery, and there is no published evidence to support the effectiveness of site-verification protocols. Further prevention strategies need to be developed to reduce the risk of wrong-site surgery. 

Read:
Longo JG et al. Errors of level in spinal surgery. An evidence based systematic review. J Bone Joint Surg Br 2012; 94-B: 1546–1550

Sutured Achilles tendon benefits from early weight bearing

BACKGROUND:The choice of rehabilitation management after the surgical repair of acute Achilles tendon (AT) ruptures remains controversial because of insufficient clinical evidence. The current study analyzes the postoperative rehabilitation of AT ruptures based on the current clinical evidence. PURPOSE:To identify and analyze the high-level clinical evidence regarding postoperative rehabilitation after the surgical repair of AT ruptures. Subgroup analyses were also performed to obtain more reliable and specific results. 

STUDY DESIGN:Meta-analysis. 

METHODS:The studies were retrieved by searching the Medline, Embase, and Cochrane databases through the OVID retrieval engine from 1990 to August 14, 2013. Two independent reviewers critically reviewed the studies using preset inclusion and exclusion criteria. The quality of the eligible studies was assessed by the Cochrane 12-item scale. All included studies were summarized, and their data were extracted. Subgroup analyses were performed according to the different protocols of early functional rehabilitation. 

RESULTS:Nine studies, consisting of 6 randomized controlled trials and 3 quasi-randomized studies, were ultimately included. A total of 402 patients were identified. Six of the included studies utilized early weightbearing combined with early ankle motion exercises, while the other 3 only employed early ankle motion exercises. The subgroup analyses demonstrated that 11 of the 15 functional outcome measurements were significantly superior for patients who underwent both early weightbearing and ankle motion exercises than for those who underwent conventional cast immobilization. Similar rates of reruptures (odds ratio [OR], 1.36; 95% CI, 0.38-4.91; P = .64) and major complications (OR, 0.67; 95% CI, 0.24-1.87; P = .44) as well as a significantly lower rate of minor complications (OR, 0.51; 95% CI, 0.27-0.95; P = .03) were also observed in this early functional rehabilitation group. For the patients who solely performed early ankle motion exercises, only 2 of the 14 functional measurements were observed to be significantly superior to immobilization. There were also no significant differences in the rates of reruptures (OR, 0.47; 95% CI, 0.08-2.70; P = .40) and other complications (OR, 1.09; 95% CI, 0.41-2.92; P = .86) between the 2 groups. 

CONCLUSION:Postoperative early weightbearing combined with early ankle motion exercises is associated with a lower minor complication rate and achieves superior and more rapid functional recovery than conventional immobilization after surgical AT repair. In contrast, few advantages were identified when only early ankle motion exercises were applied.

Huang J et al. Rehabilitation Regimen After Surgical Treatment of Acute Achilles Tendon Ruptures. A Systematic Review With Meta-analysis. Am J Sports Med 2014; online 2. Mai; doi: 10.1177/0363546514531014