International Academy of Manual/Musculoskeletal Medicine, Annual Meeting at Berlin, October 2014

s 1. The efficacy of shoulder treatments: An update O. Airaksinen, Manual/Musculoskeletal Medicine the members of the Efficacy Committee of the International Academy of Department of Physical and Rehabilitation Medicine, Kuopio University Hospital, Kuopio, Finland Email: Olavi.Airaksinen@kuh.fi Current literature suggests that the commonest presentations of shoulder pain are due to subacromial impingement syndrome (48–72%), adhesive capsulitis (16–22%), and acute bursitis (e.g.17%). We considered our review of the literature for treatments under three headings: 1. Subacromial inflammation and impingement • Shape of acromion. The acromion may become more curved with progression of degenerative change, but this shows no association with the presence of rotator cuff disease: suggesting that surgical treatments are not necessary for acromial shape alone. A 750% increase in shoulder arthroscopies for subacromial decompression has been recorded in England in the ten years to 2010. • Supervised exercises for impingement. Arthroscopic surgery has been compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome). One hundred and twenty-five patients aged 18–66 yeas who had had rotator cuff disease for at least three months and whose condition was resistant to treatment were randomized to receive either (a) arthroscopic subacromial decompression performed by two experienced surgeons; or (b) an exercise regimen over three to six months supervised by one experienced physiotherapist; or 12 sessions of detuned soft laser treatment over six weeks. Analysis showed that either surgery or a supervised exercise regimen significantly, and equally, improved rotator cuff disease compared with placebo. They also compared the costs of the two regimens: the supervised exercises were just over half the cost of the surgery. A follow-up study showed that after 2.5 years, both arthroscopic surgery and supervised exercises are better treatments than placebo. A two-year randomised controlled trial by Ketola et al. concluded that arthroscopic acromioplasty provides no clinically important effects over a structured and supervised exercise programme alone in terms of subjective outcome or cost-effectiveness when measured at 24 months. Structured exercise treatment should be the basis for treatment of shoulder impingement syndrome, with operative treatment offered judiciously until its true merit is proven. Their five-year follow-up study showed no evidence of long-term benefits of arthroscopic acromioplasty in the treatment of shoulder impingement syndrome. The effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome was examined in a randomized controlled study. Strengthening with concentric and eccentric exercises and with stabilizing the scapula was used. The study showed that these reduce pain and decrease need for arthroscopic surgery. Studies of surgical interventions in subacromial impingement syndrome suggested that no technique is convincingly better than another or than conservative interventions. Recommendations for impingement Procedure: Active physiotherapy exercises at least 2 times weekly both concentric and eccentric with stabilizing of the scapula. Evidence: Exercises versus arthroscopic decompression in patients with subacromial impingement stage II have shown equal efficacy up to 4 years follow-up (Evidence: A). Quality of trials: Five good quality randomized controlled trials with follow-up to 5 years. Recommendation: Exercises (up to 6 months) should be used as first-line therapy for impingement syndrome of the shoulder (A). 2. Degenerative rotator cuff disease The conclusions of the Cochrane collaboration in September 2012 were: Exercises: Exercise was demonstrated to be effective in terms of short term (<6 months) recovery in rotator cuff disease (RR 7.74 (1.97, 30.32), and longer term >6 months) benefit with respect to function (RR 2.45 (1.24, 4.86). Combining mobilization with exercise resulted in additional benefit when compared to exercise alone for rotator cuff disease. Their recommendation: There is moderate evidence to use shoulder exercise therapy for degenerative rotator cuff disease patients (B). Steroid injection: For subacromial inflammation conditions triamcinolone acetate should be used (A). Nonsteroidal anti-inflammatory drugs for shoulder pain: Moderate and strong evidence for short-term (2 weeks up to 3 months) pain relief for inflammatory conditions of the subacromial space. They recommend that nonsteroidal anti-inflammatory drugs should be used for short term pain relief taking account the adverse events (gastrointestinal bleeding, cardiovascular, and so on) (A). 3. Adhesive capsulitis Corticosteroids. Evidence: Steroid injections intraarticularly were superior to physiotherapy including exercises (A) for adhesive capsulitis. Benefit shown International Academy of Manual/Musculoskeletal Medicine International Musculoskeletal Medicine 2014 VOL. 36 NO. 4 158 up to 12 weeks. (B) Ultrasound-guided or not: not enough trials. There is moderate (B) level evidence that arthrographic distension with saline and steroid provides short-term benefits in pain, range of movement and function in adhesive capsulitis. Manipulation under anaesthesia does not add effectiveness to an exercise program carried out by the patient after instruction. (B) Recommendation: Manipulation under anaesthesia should not be used for adhesive capsulitis as a first line treatment. (B) Physiotherapy following joint distension provided no additional benefits in terms of pain, function, or quality of life but resulted in sustained greater active range of shoulder movement and participantperceived improvement up to 6 months. Recommendation: Physiotherapy and home exercise can be used as first line therapy for adhesive capsulitis. (B) Acupuncture for shoulder pain. Evidence: there is little evidence to support or refute the use of acupuncture for shoulder pain although there may be short-term benefit with respect to pain and function (C). Recommendation: acupuncture will be recommended for carefully selected patients for pain relief (C). Our Recommendations are: Exercise for impingement (A) Exercise for Degenerative Rotator Cuff Disease (B) Nonsteroidal anti-inflammatory drugs for pain (A) Injection of corticoids for subacromial inflammation and capsulitis (B) Acupuncture for pain (C) Mobilization (C)