My First Experience with Epidural Steroid Injections
Treatments for Shoulder Impingement SyndromeE-Mail-Adresse Kennwort Angemeldet bleiben. Um Ihnen ein bestmögliches Nutzererlebnis zu bieten, verwenden wir auf unserer Webseite Cookies und den "Besucheraktions-Pixel" von Facebook. Wenn Sie unsere Webseite weiter nutzen, stsroid wir davon aus, dass Sie mit der Verwendung der Cookies einverstanden sind. Dies steroid injection recovery zum Verlust des Transplantats führen. Ein Vorgehen bei Kindern mit
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. 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 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.
Shoulder pain is a common presenting complaint from patients of all ages in daily clinical practice, affecting approximately one-third of individuals during their lifetime. Pain at night is another important complaint in these patients. Concurrently, a general loss of muscle strength may be noted. Neer graded SIS into 3 different stages. In stage II, chronic inflammation or repeated episodes of impingement lead to histomorphological changes, such as fibrosis and thickening of the supraspinatus, the long biceps tendon, and subacromial bursae.
Patients in this stage are usually between 25 and 40 years of age. In stage III, in patients more than 40 years of age, tears of the rotator cuff, rupture of the biceps tendon, and bony changes may be observed, accompanied by significant tendon degeneration following a long history of refractory tendinitis. The main goals of SIS treatments are to relieve pain and to solve the mechanical problem causing the functional impairment.
The SIS treatment strategy varies according to disease stage. At an early stage of SIS, which usually refers to stage I or early stage II, some nonoperative treatments may be effective, such as muscle exercises, for example, the training of the periscapular muscles pectoralis minor, trapezius, serratus, and rhomboids and strengthening of the rotator cuff supraspinatus, infraspinatus, teres minor, and subscapularis , which functions as the stabilizer of the shoulder joint.
Some investigators have also reported on many other nonoperative treatment methods, such as pulsed electromagnetic field therapy, 5 , 6 manual therapy, 7 — 10 kinesio taping therapy, 11 , 12 localized drug injection of corticosteroids, hyaluronate, or NSAIDs, 11 — 18 diacutaneous fibrolysis therapy, 19 specific exercise therapy that includes concentric and eccentric exercises for the scapula stabilizers and dynamic humeral centering and scapular stabilization exercises, 20 — 22 microwave diathermy therapy, 23 ultrasound therapy, 24 low-level laser therapy, 24 — 28 radial extracorporeal shockwave therapy, 29 and acupuncture therapy.
However, for other patients, operative treatment should be considered. However, the abundance of treatment choices do not necessarily facilitate the physician's decision making but rather indicates that no consensus exists regarding which treatment options are suitable. Many RCTs have been conducted to compare the effectiveness of different treatments, supporting certain conclusions.
Some systematic reviews have also been published that concentrated only on the pair-wise comparison of different treatments, but no review including all of the available treatments has been conducted.
Due to the limitations of the existing reviews and the fact that many relatively new studies have been published, a prominent need exists to conduct an accurate and comprehensive review of this topic. Network meta-analysis enables comparisons of the effectiveness of all treatments considered. Furthermore, the statistical method based on Bayesian theory enables calculation of the rank probability for each treatment. Clearly, this approach is in accordance with actual situations in daily clinical practice.
In this review, we have endeavored to provide useful information regarding comparisons among all treatments for SIS. We hope that the results will aid physician decision making. Randomized controlled trials that included all of the following criteria were considered eligible: The Medline and Embase databases were searched together via www. Additionally, all of the available reviews related to SIS treatments were manually screened for any additional possibly relevant studies.
No language limit was applied. List 1 Search Strategy used in www. Two independent reviewers WD and X-BL screened the title and abstract of the retrieved articles, and the full text was reviewed as necessary. The studies that were potentially relevant according to the eligibility criteria were selected. Disagreements regarding study inclusion were resolved by discussion, and in cases of persistent disagreement, a third reviewer Z-LW was consulted.
In cases where the author provided more than 1 follow-up data point, the time point closest to 12 months was adopted. The data were then integrated by WD. Discrepancies between the 2 data extraction results were reviewed by WD and were then resolved by discussion. Similarly, a third reviewer T-YZ was consulted if agreement could not be reached between these 2 reviewers. The evaluation of the primary outcome of pain score was performed based on the visual analog scale VAS pain score, the numerical rating scale NRS pain score, and the Likert pain score.
The original values of these pain scores were then adjusted to the range of 0 to 10 0 for no pain and 10 for the worst imaginable pain. The secondary outcome of the CMS encompassed subjective pain and daily activities and objective range of motion and strength assessments range from 0 to , with higher scores being better. Because patients who underwent surgery usually had a worse condition and a longer disease course than those who were treated nonoperatively, as well as because most of them had already undergone nonoperative treatments at an earlier time, we separated the studies into 2 subgroups according to their focus on nonoperative treatments or operative treatments.
These 2 subgroups were then analyzed. In some studies, exercise therapy was compared with surgical treatments; in these cases, the studies were absorbed into the operative treatment subgroup. Interventions employing the same principles but different approaches were assigned the same treatment name.
Finally, the interventions were grouped into 20 treatment strategies; some of which represented combinations of 2 treatments. First, the pair-wise meta-analysis was conducted using a random-effects model. The results of the studies that compared the same pair of treatments were synthesized. Altogether, 4 networks were built as follows: Four Markov chains were run for 40 , iterations simultaneously. A thinning interval of 10 was applied, indicating that 1 sample was collected every 10 iterations.
The first 10, iterations were considered as burn-in iterations, and no sample was collected during this period because these iterations may have been affected by the arbitrary values assigned at the starting point of each chain. The Brooks—Gelman—Rubin method was used to assess convergence. A PSRF very close to 1 was considered to indicate an approximate convergence. The probability of rank for each treatment was also estimated by calculating the MD compared with that of any other treatments.
Next, a Z test was performed to examine the inconsistency of the model. The rank probabilities were again calculated. If there was no significant change, the outcome of the meta-analysis was considered to be reliable. Additionally, a meta-regression was performed to ascertain the relationship between the sample size and the treatment effect using the method recommended by the UK's National Institute for Health and Care Excellence.
Moreover, the deviance information criterion DIC was used as the measure of model fit. A lower DIC value was preferred because it suggested a more parsimonious model. According to the search strategy, records were identified. After the titles and abstracts were screened, a total of 94 records were screened for eligibility by full-text review. Of these 52 articles, 4 articles 49 — 52 were focused on treatments that did not match treatments in other articles, 1 article 35 was derived from an included study but reported different follow-up results, 6 articles 33 , 53 — 57 used outcome measurements other than the pain score and CMS, and the pain score or CMS results were reported in the other 8 articles, 34 , 37 , 58 — 63 but the articles were not suitable for statistical analysis.
The findings from these articles were also included in the discussion section. Finally, 33 RCTs were included in the quantitative synthesis procedure. The networks of nonoperative treatments included 28 studies 26 reported the pain score and 12 reported the CMS , whereas the networks of operative treatments included 5 studies 5 reported the pain score and 3 reported the CMS.
A total of patients were included in the studies, of whom received nonoperative treatments and of whom underwent operative treatments.
The following standardized headings were extracted: As the clinical involved many different treatments, the blinding of treatment performance appeared difficult. Moreover, the blinding of outcome assessment was clearly described in only 14 of the 33 studies. All data, which were suitable for conventional pair-wise meta-analysis, were entered into STATA, and random-effects models were developed.
Regarding nonoperative treatments, 19 pairs of pain score comparisons were performed. No significant difference was detected in the remaining 15 comparisons. Regarding operative treatments, none of the comparisons 4 pairs for pain score and 2 pairs for CMS showed significant differences.
The iterations showed good convergence, as revealed by the strong linearity in the graphical diagnostic plots. Moreover, the PSRFs of parameters were all unlimitedly close to 1 without exception, which also represented good convergence. Nonoperative treatments pain score. Operative treatments pain score. However, with respect to the CMS, the network meta-analysis showed better concordance with the conventional pair-wise meta-analysis. Regarding operative treatments, the results of both the network comparisons and pair-wise comparisons of the pain score and CMS also showed no significant differences.
Because EXE was the most commonly used treatment in clinical practice, a series of comparisons between other nonoperative treatments and EXE were performed. If another therapy were added to EXE, a better effect may be achieved. A Treatments compared with EXE pain score. Rank probability indicated the possibility of each treatment being the best, the second best, and so forth down to the worst treatment.
A Rank probability of nonoperative treatments pain score. B Rank probability of nonoperative treatments CMS. C Rank probability of operative treatments pain score.
Treatments for Shoulder Impingement Syndrome
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