Saturday, July 22, 2017

Treatment for rotator cuff disease - what do the Cochrane reviews say?

Cochrane in CORR®: Manual Therapy and Exercise for Rotator Cuff Disease

These authors point out that rotator cuff disease accounts for more than 70% of shoulder complaints and is one of the most common musculoskeletal disorders in the adult population where its prevalence ranges from 7% to 26%. The term 'rotator cuff disease' is broad and encompasses acute and chronic pathology affecting the shoulder joint, including rotator cuff tears, tendonitis, and other similar pathologies. Individuals affected by this condition commonly describe debilitating pain with movement, particularly during overhead activities, as well as pain being worse at night. In the United States, rotator cuff tendinopathy accounts for approximately 4.5 million annual physician visits, with treatment and management reaching an estimated $3 billion annually. If one includes indirect costs, such as lost time from work, this number is even larger.

Against this background, there is a need for solid evidence on the effectiveness of different methods of treatment.

These authors summarized a recent Cochrane review that evaluated the efficacy of exercise or manual therapy in the setting of rotator cuff disease, and concluded that no clinical benefit exists for such interventions over placebo or other treatments.

Comment: The results of this review need to be viewed in the light of another recent Cochrane review:

Surgery for rotator cuff disease
This review is one in a series of Cochrane reviews of interventions for shoulder disorders. Its goal was to determine the effectiveness and safety of surgery for rotator cuff disease.

The authors searched the Cochrane Controlled Trials Register, (The Cochrane Library Issue 1, 2006), MEDLINE, EMBASE, CINAHL, Sports Discus, Science Citation Index (Web of Science).
Only studies described as randomised or quasi-randomised clinical trials (RCTs) studying participants with rotator cuff disease and surgical interventions compared to placebo, no treatment, or any other treatment were included. Two independent review authors assessed methodological quality of each included trial and extracted data.

They included 14 RCTs involving 829 participants. Eleven trials included participants with impingement, two trials included participants with rotator cuff tear and one trial included participants with calcific tendinitis. No study met all methodological quality criteria and minimal pooling could be performed. Three trials compared either open or arthroscopic subacromial decompression with active non operative treatment (exercise programme, physiotherapy regimen of exercise and education, or graded physiotherapy strengthening program). No differences in outcome between these treatment groups were reported in any of these trials. One trial which also included a placebo arm (12 sessions detuned soft laser) reported that the Neer score of participants in both active treatment arms improved significantly more than those who received placebo at six months.

Based upon our review of 14 trials examining heterogeneous interventions and all susceptible to bias, the authors could not draw firm conclusions about the effectiveness or safety of surgery for rotator cuff disease.

From these two Cochrane reviews, it appears that we need better evidence on which to base the treatment for what is perhaps the most common shoulder disorder.

The reader may also be interested in these posts:

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