ARTICLE

Conservative versus Surgical Interventions for Shoulder

Impingement: An Overview of Systematic Reviews of
Randomized Controlled Trials
Goris Nazari, MSc, PhD (C), PT;*{ Joy C. MacDermid, PhD, PT;*{‡
Pavlos Bobos, MSc PhD (c), PT *{

ABSTRACT
Purpose: Numerous systematic reviews (SRs) of randomized controlled trials (RCTs) have emerged that investigate the effectiveness of conservative (super-
vised exercises) versus surgical (arthroscopic subacromial decompression) interventions for patients with shoulder impingement; however, there are dispa-
rities in the quality of the evidence synthesized. The purpose of this study was to conduct an overview of SRs of RCTs to critically appraise the evidence
and establish the current state of effectiveness of conservative versus surgical interventions on clinical outcomes among patients with shoulder impinge-
ment. Method: The MEDLINE, EMBASE, CINAHL, and PubMed electronic databases were searched for January 2008 to September 2018, and we found
SRs of RCTs of patients with shoulder impingement, subacromial pain syndrome, or subacromial impingement syndrome who had received conservative
versus surgical interventions to improve outcomes. Two authors extracted the data, and two independent review authors assessed the risk of bias and qual-
ity. Results: A total of 15 SRs were identified. One was rated as high quality, 7 as moderate quality, 5 as low quality, and 2 as critically low quality. The re-
sults were in line with one another, indicating that no differences in outcomes existed between conservative and surgical interventions among patients with
shoulder impingement. Conclusion: There were no clinically important or statistically significant differences in outcomes between conservative versus sur-
gical interventions among patients with subacromial impingement syndrome. To enhance clinical outcomes in this patient population, shoulder-specific ex-
ercises that aim to improve muscle strength and flexibility must be considered as the first line of conservative treatment.
Key Words: conservative treatment; randomized controlled trials; surgery; systematic review.

RÉSUMÉ
Objectif : de nombreuses analyses systématiques (AS) de récents essais aléatoires et contrôlés (EAC) portent sur l’efficacité d’une intervention prudente
(exercices supervisés) au lieu d’une opération (arthroscopie sous-acromiale) chez les patients ayant une impaction de l’épaule, mais la qualité des données
synthétisées est hétérogène. La présente étude visait à faire un survol des AS d’EAC pour procéder à une analyse critique des données probantes et déter-
miner l’efficacité des interventions prudentes par rapport aux opérations sur la situation clinique des patients ayant une impaction de l’épaule. Méthodolo-
gie : les chercheurs ont fouillé les bases de données de MEDLINE, EMBASE, CINAHL et PubMed entre janvier 2008 et septembre 2018 et trouvé des AS
d’EAC de patients présentant une impaction de l’épaule, un syndrome d’accrochage sous-acromial ou un syndrome de conflit sous-acromial qui ont subi
une intervention prudente ou une opération pour améliorer leur situation clinique. Deux auteurs ont extrait les données, et deux auteurs indépendants ont
évalué le risque de biais et la qualité. Résultats : Au total, les chercheurs ont extrait 15 AS. L’une était de haute qualité, sept, de qualité modérée, cinq, de
basse qualité, et deux, de qualité dangereusement faible. Les résultats étaient équivalents les uns aux autres, c’est-à-dire que les résultats cliniques des in-
terventions prudentes ne différaient pas de ceux des opérations chez les patients présentant une impaction de l’épaule. Conclusion : les chercheurs n’ont
constaté aucune différence importante sur le plan clinique ou statistiquement significative entre les résultats cliniques d’une intervention classique et ceux
d’une opération chez les patients présentant un syndrome de conflit sous-acromial. Pour améliorer la situation clinique de cette population de patients, le
traitement prudent de première ligne consiste à envisager des exercices de l’épaule pour améliorer la force et la flexibilité.
Mots-clés : analyse systématique; essais aléatoires et contrôlés; opération; traitement prudent

Shoulder pain is regarded as the third most prevalent rotator cuff–related conditions such as impingement syn-
type of musculoskeletal disorder and affects one in three drome is 65%–70% in the adult population.2–3 Shoulder
individuals.1 It has been estimated that the prevalence of pain may be a major symptom of shoulder impingement

From the: *School of Physical Therapy, Faculty of Health Sciences; {Collaborative Program in Musculoskeletal Health Research, Bone and Joint Institute, Western Uni-
versity; ‡Roth McFarlane Hand and Upper Limb Centre, St. Joseph’s Hospital, London, Ont.
Correspondence to: Goris Nazari, School of Physical Therapy, Faculty of Health Sciences, Elborne College, Western University, 1151 Richmond Street, London,
ON N6A 3K7; gnazari@uwo.ca.

Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft.

Competing Interests: None declared. The authors received no specific funding for this work. Goris Nazari is supported by the Transdisciplinary Bone and Joint Train-
ing Award and the Collaborative Training Program in Musculoskeletal Health Research at Western University. Pavlos Bobos is supported by a Canadian Institutes of
Health Research (CIHR) Doctoral Research Award. Joy C. MacDermid was supported by a CIHR Chair in Gender, Work and Health and the Dr. James Roth Research
Chair in Musculoskeletal Measurement and Knowledge Translation.
Physiotherapy Canada 2020; 72(3); 282–297; doi:10.3138/ptc-2018-0111

282
Nazari et al. Conservative versus Surgical Interventions for Shoulder Impingement: An Overview of Systematic Reviews of RCTs
syndrome,4 and it is considered to be one of the main
sources of a reduction in quality of life and a decrease
in shoulder joint function.5 Studies of the effectiveness
of nonsteroidal anti-inflammatory drugs, corticosteroid
injection, and conservative approaches (exercise) have
been conducted to investigate outcomes in patients with
shoulder impingement syndrome.6–10
Conservative interventions, including exercises, are
intended to improve muscle function as well as range of
motion by restoring shoulder mobility, proprioception,
and stability.11 Numerous systematic reviews (SRs) inves-
tigating the effectiveness of conservative versus surgical
interventions in patients with shoulder impingement
have emerged;11–25 however, the quality of evidence
synthesized by these SRs varies. Given the large increase
in the number of published SRs on this topic over the
past 3 years, an overview of SRs of randomized controlled
trials (RCTs) was warranted to summarize the evidence
for use by researchers, clinicians, funding agencies, and
policy-makers to assist decision making and evidence
translation.
Therefore, we aimed to conduct an overview of SRs of
RCTs to critically appraise the evidence and establish
the current state of effectiveness of conservative (with an
exercise component) versus surgical interventions on clini-
cal outcomes among patients with shoulder impingement.
METHODS
Designing the study
This study was an overview of SRs of RCTs. The PROS-
PERO registration number is CRD42018109357.
Determining the eligibility criteria
We set out to find SRs that met the following popula-
tion, intervention, comparison, and outcome (PICO)
components:
• Population: patients with shoulder impingement, suba-
cromial pain syndrome, or subacromial impingement
syndrome (compression of rotator cuff muscles and
tendons evident from radiological changes, clinical
symptoms, or both)21
• Intervention: conservative (with exercise component)
• Comparison: surgical interventions
• Outcome: function or disability, pain, range of motion,
and strength.
SRs of non-RCTs; narrative, critical, or scoping reviews;
and conference abstracts or posters were excluded.
Conducting the search
An electronic search for SRs published in English
between January 2008 and September 2018 was con-
ducted in the following databases: MEDLINE, EMBASE,
CINAHL, and PubMed. Moreover, we searched the PROS-
PERO database and the reference lists of the selected SRs
283
and RCTs to identify other eligible SRs. Our search strat-
egy is summarized in the Appendix.
Selecting the studies
Two independent reviewers (GN and PB) performed
the electronic searches in each database. Duplicate SRs
were identified and removed. Next, we independently
screened the titles and abstracts and retrieved in full text
any article marked include or uncertain by either
reviewer. Finally, we conducted an independent full-text
review to assess final eligibility. In case of disagreement,
a third reviewer (JCM) helped achieve consensus through
discussion.
Extracting the data
Data extraction was performed by two authors (GN
and PB). Descriptive characteristics were extracted from
the eligible SRs by including (1) author and year, (2) pop-
ulation, (3) risk of bias, (4) quality of evidence assessment
(without rescoring), (5) reported outcomes, and (6) re-
sults or conclusions made by the authors of the reviews.
Reporting the quality of the randomized controlled trials in the
selected systematic reviews
We did not rescore the quality of the RCTs included in
the SRs but instead reported the quality of each SR ac-
cording to its authors’ assessment. When an RCT was in-
cluded in two or more SRs, we reported this, along with
any variation in the SR authors’ assessments of study
quality.
Assessing the quality of the evidence
Several tools were originally used by the SRs selected
for our study to assess the quality of the individual stu-
dies.
Grading of Recommendations Assessment, Development and
Evaluation
The Grading of Recommendations Assessment, Devel-
opment and Evaluation (GRADE) approach takes into
account the risk of bias, publication bias, consistency of
findings, precision, and applicability of the overall body
of literature to provide a high, moderate, low, or very low
rating of the quality of evidence.11
Physiotherapy Evidence Database scale
The Physiotherapy Evidence Database (PEDro) scale
uses eight criteria to assess the internal validity of a trial
and two criteria to determine the sufficiency of the statis-
tical information displayed in a trial. One criterion is con-
cerned with whether a study provides both point
measures and measures of variability. Each criterion can
be marked yes or no, where yes = 1 point and no = 0 points
on the final rating scale.16
Scottish Intercollegiate Guidelines Network criteria
The Scottish Intercollegiate Guidelines Network
(SIGN) criteria are used to assess the internal validity of
284
an RCT, and assessment involves examining 10 method-
ological criteria: (1) clarity of the research question, (2)
randomization method, (3) appropriate concealment of
treatment allocation, (4) blinding of treatment and out-
comes, (5) similarity of between-groups baseline charac-
teristics, (6) the co-intervention and contamination
involved, (7) the extent of reliability and validity of
outcome measures, (8) attrition rate, (9) whether an
intention-to-treat analysis was performed, and (10) how
comparable the results are across study sites.24
Cochrane Musculoskeletal Group
The Cochrane Musculoskeletal Group (CMSG) guide-
lines use four levels of quality of evidence: platinum, gold,
silver, and bronze. To achieve platinum-level evidence, an
SR of at least two RCTs must meet the following criteria:
(1) sample size of at least 50 participants per group, (2) pa-
tients and outcome assessors blinded, (3) adequate hand-
ling of withdrawals of more than 80% at follow-up, and (4)
concealment of allocation performed. To achieve gold-
level evidence, an SR of at least one RCT must meet the
following criteria: (1) sample size of at least 50 participants
per group, (2) patients and outcome assessors blinded, (3)
adequate handling of withdrawals of more than 80% at
follow-up, and (4) concealment of allocation performed.
Silver-level evidence is an SR or RCT that does not meet
the criteria for platinum- or gold-level evidence. Bronze-
level evidence is a high-quality case series without con-
trols or that is derived from expert opinion.25
Assessing the risk of bias
Two independent reviewers (GN and PB) applied the
Measurement Tool to Assess Systematic Reviews (AM-
STAR 2) risk-of-bias tool to assess the risk of bias in the
selected SRs.26 In case of disagreement, a third reviewer
(JCM) helped achieve consensus through discussion. AM-
STAR 2 scores items in 16 colour-coded domains: inclu-
sion of PICO components, protocol registered before
commencement of SR, description of study selection cri-
teria, adequacy of literature search, whether study selec-
tion and data extraction were performed in duplicate,
justification for exclusion of studies, detailed description
of selected studies, assessment of risk of bias for individ-
ual studies, statement of source of funding, appropriate-
ness of meta-analytical methods, meta-analysis based on
risk of bias, consideration of risk of bias when interpret-
ing the results of the SR, explanation and discussion of
heterogeneity, assessment of likely impact of publication
bias, and potential sources of conflict of interest.26 Each
domain is scored and colour coded as yes (green), partial
yes (yellow), no (red), or not applicable (grey).
The overall AMSTAR 2 rating of confidence (quality)
can be interpreted as follows:
• High – No, or one, non-critical weakness: the SR pro-
vides an accurate and comprehensive summary of the
Physiotherapy Canada, Volume 72, Number 3
results of the available studies that address the question
of interest.26
• Moderate – More than one non-critical weakness: The
SR has more than one weakness but no critical flaws. It
may provide an accurate summary of the results of the
available studies that were included in the review.26
• Low – One critical flaw with or without non-critical
weaknesses: The SR has a critical flaw and may not pro-
vide an accurate and comprehensive summary of the
available studies that address the question of interest.26
• Critically low – More than one critical flaw with or with-
out non-critical weaknesses: The SR has more than one
critical flaw and should not be relied on to provide an
accurate and comprehensive summary of the available
studies.26
Synthesizing the data
We performed a qualitative synthesis of the data and
summarized the main results of the selected SRs on the
basis of the AMSTAR 2 quality ratings.
RESULTS
Selecting the systematic reviews
Our initial search yielded 455 publications (422 from
the database search and 33 from the PROSPERO database
and reference lists). After removing duplicates, 281 articles
remained and were screened using their title and abstract;
this left 43 articles selected for full-text review. Of these, 15
SRs were eligible for our analysis.11–25 A flowchart showing
the selection process is presented in Figure 1.
Characteristics of the selected systematic reviews
The effectiveness of conservative versus surgical inter-
ventions on clinical outcomes in patients with shoulder
impingement was evaluated in the 15 eligible SRs.11–25 All
15 SRs reported the outcomes of function or disability and
pain,11–25 7 SRs reported range of motion,11–14,16,22,24 and 4
SRs reported strength.11,14,22,24 The characteristics of the
selected SRs are summarized and presented in Table 1.
Risk-of-bias assessment in the selected systematic reviews
The selected SRs evaluated the risk of bias using the
following assessment tools:
• CMSG guidelines: six SRs11–12,15,19,21,25
• PEDro scale: two SRs14,16
• SIGN: two SRs20,24
• Furlan: one SR17
• 11-domain list: one SR18
• 3-domain list: one SR13
• Unclear (not reported): two SRs.22–23
Assessing the quality of evidence in the selected systematic
reviews
The quality of evidence was assessed using the follow-
ing assessment tools:
Nazari et al. Conservative versus Surgical Interventions for Shoulder Impingement: An Overview of Systematic Reviews of RCTs 285

Records identified through database searching

MEDLINE (n = 79) Reviews identified through PROSPERO database
EMBASE (n = 47)
CINAHL (n = 31)
and reference lists
n = 33
Identification

PubMed (n = 265)
n = 422

Records after duplicates removed

n = 281
Screening

Titles screened Reviews excluded

n = 281 n = 137

Abstracts screened Reviews excluded

n = 144 n = 101
Eligibility

Full-text reviews assessed for Reviews excluded

eligibility n = 28
n = 43 • Irrelevant intervention
(n = 25)
• Inappropriate study design
Studies selected in qualitative (n = 3)
synthesis
n = 15
Included

Studies included in quantitative

synthesis
(meta-analysis)
n=0

Figure 1 Flowchart of process to select systematic reviews to be selected in the overview.

• GRADE: three SRs11–12,16
• Best-evidence synthesis approach: six SRs14–15,18,20–21,24
• PEDro scale: two SRs22–23
• CMSG guidelines: one SR25
• Furlan criteria: one SR17
• Not reported: one SR19
• Unclear: one SR13
Assessing the quality of the systematic reviews using the
Measurement Tool to Assess Systematic Reviews 2
Using AMSTAR 2, we rated the quality of the 15 SRs
as follows: 1, high;11 7, moderate;12,16,18,20,21,24,25 5,
low;15,17,19,22,23 and 2, critically low.13–14 Regarding the
tool’s critical domains, 10 SRs did not perform a priori
registration,12–14,16–19,21–23 and 2 partially met the com-
prehensive search criteria.16,17 Two SRs did not provide
justification for the excluded studies,13,21 and 7 partially
used a satisfactory technique for assessing the risk of bias
of the primary studies.14,16,18,20,22–24 Six SRs did not con-
sider the risk of bias when interpreting their re-
sults,13,14,17,19,22,23 and 4 did not assess the presence or
likely impact of publication bias in the selected stu-
dies.14,15,19,25 A summary of the AMSTAR 2 ratings is pre-
sented in Table 2.
High-quality systematic reviews
We rated one SR as high-quality evidence.11 This SR
included very low- to low-quality RCTs and used the Co-
chrane Collaboration’s tool for assessing the risk of bias
and the GRADE approach for assessing the quality of evi-
dence. It showed no clinically important or statistically
significant differences in outcomes (function, pain, range
of motion, strength) between supervised exercises and
arthroscopic subacromial decompression in patients
with subacromial impingement syndrome at 6 and 12
months or global treatment success at 4–8 years.11 More-
over, no events were reported in either group.
Moderate-quality SRs
We rated seven SRs as having moderate-quality evi-
dence.12,16,18,20,21,24,25 Using GRADE, one SR included
very low-quality RCTs.12 It showed no differences in
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Table 1 Characteristics of Selected Systematic Reviews, Results or Conclusions, and Rating of Confidence Using AMSTAR 2

Risk-of-bias Quality of evidence* AMSTAR

Author Population Studies assessment tool (assessment tool) Outcomes Results or conclusions{ 2 quality

Page et al.11 Subacromial Brox et al.,27 Haahr et al.28 Cochrane Collaboration’s Very low to low quality Function, pain, range“All differences in outcomes between supervised High
impingement tool for assessing risk of (GRADE) of motion, global exercises and arthroscopic subacromial
syndrome bias treatment success, decompression were not clinically important or
adverse events, statistically significant. Zero events in both
strength groups”11(p.23-24); “Low quality evidence from one
trial showed no important differences between
exercise (plus heat, cold packs or soft tissue
treatment) vs arthroscopic subacromial
decompression with respect to overall pain,
function, active range of motion and strength at
6- and 12-months, or global treatment success at
four to eight years.”11(p.24)
Steuri et al.12 Shoulder Ketola et al.,26 Brox et al.,29 Cochrane Collaboration’s All outcomes – very low Function or disability, “Although our review only provides very low- Moderate
impingement Peters & Kohn,30 Rahme tool for assessing risk of quality (GRADE) pain, range of quality evidence, we suggest that exercise may
et al.,31 Farfaras et al.,32 bias motion be considered as the core conservative treatment
Haahr et al.,33 Haahr & for shoulder impingement. Furthermore, manual
Andersen,34 Ketola et al.35 therapy, laser and tape might provide additional
benefit. Surgery may be a valid alternative after
unsuccessful conservative treatments, and for
patients with clearly distinguished clinical signs.”
12(p.8)
“Exercise, especially shoulder-specific
exercises, should be prescribed for all patients
with shoulder impingement.”12(p.8)
Haik et al.16 Subacromial pain Brox et al.,27 Haahr et al.28 PEDro scale All outcomes – Function, pain, range “According to the body of evidence synthesized, Moderate
syndrome moderate quality of motion exercise therapy aimed at restoring muscle
(GRADE) flexibility and strength of shoulder and scapular
muscles should be used as the first-line
treatment to improve pain, function and range of
motion in individuals with subacromial pain
syndrome (SAPS) before recommending
arthroscopic surgery.”16(p.11)
Goldgrub Subacromial Haahr et al.,28 Haahr & SIGN criteria No evidence (best- Function, pain, range “We did not find evidence (no statistically Moderate
et al.24 impingement Andersen34 evidence synthesis) of motion, strength significant differences) that multimodal care (heat
syndrome application, cold application, soft tissue therapy,

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Physiotherapy Canada, Volume 72, Number 3
Table 1 (continued )

Risk-of-bias Quality of evidence* AMSTAR

Author Population Studies assessment tool (assessment tool) Outcomes Results or conclusions{ 2 quality

supervised exercises, home exercise)

programmes are more effective than surgery
followed with exercises for persistent subacromial
impingement syndrome.”24(p.136)
Saltychev Shoulder Brox et al.,27 Haahr et al.,28 Cochrane Collaboration’s No evidence for all Function or disability, “There is no evidence of surgery being more Moderate
et al.21 impingement Brox et al.,29 Peters & tool for assessing risk of outcomes; pain pain, restriction of effective than conservative methods in the
Kohn,30 Rahme et al.,31 bias outcome: moderate movement treatment of shoulder impingement. There is
Haahr & Andersen,34 Ketola quality (best-evidence moderate evidence that surgery and conservative
et al.35 synthesis) methods have similar effect on reduction of pain
intensity amongst patients with shoulder
impingent in stage two.”24(p.7)
Abdulla et al.20 Subacromial Ketola et al.35,36 SIGN criteria Limited or low quality Pain, disability “For persistent subacromial impingement Moderate
impingement (best-evidence syndrome, supervised and home-based
syndrome synthesis) strengthening exercise leads to similar outcomes
as surgery plus post-surgical
rehabilitation.”20(p.655)
Coghlan Impingement, Brox et al.,27 Haahr et al.,28 Cochrane Collaboration’s All outcomes: silver Function, pain “There is evidence from three trials that there is Moderate
et al.25 Stage II Rahme et al.31 tool for assessing risk of level (CMSG) no difference in outcome between surgery and
impingement bias active non-operative treatment for impingement
syndrome syndrome.”25(p.10)
Dorrestijn Subacromial Brox et al.,27 Haahr et al.,28 11-domain list Medium to low quality Function, pain “No confident conclusion can be made based on Moderate
et al.18 impingement Peters & Kohn,30 Rahme (best-evidence the results available. The randomized controlled
syndrome et al.,31 Haahr & Andersen34 synthesis) trials included in this review failed to provide
evidence for differences in outcome between
conservatively- and surgically-treated patients
with subacromial impingement syndrome (SIS).
Whether this failure is due to impairments in
Nazari et al. Conservative versus Surgical Interventions for Shoulder Impingement: An Overview of Systematic Reviews of RCTs

methodological quality or a lack of difference in

treatment outcome remains unclear.”18(p.53)
Dong et al.19 Shoulder Haahr et al.28 Cochrane Collaboration’s Not reported Function, pain “Exercise and other exercise-based therapies are Low
impingement tool for assessing risk of the most important treatment options for
syndrome bias [shoulder impingement syndrome] SIS patients.
For those patients who seek nonoperative
treatment option[s] at an early stage of SIS,

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287
 288

Table 1 (continued )

Risk-of-bias Quality of evidence* AMSTAR

Author Population Studies assessment tool (assessment tool) Outcomes Results or conclusions{ 2 quality

exercise combined with other therapies should be

recommended.”19(p.15) “For patients with chronic
SIS, operative treatment options may be
considered. Notably, however, the decision for
operative treatment should be made cautiously
because similar outcomes may also be achieved
by the implementation of exercise therapy.”19(p.15)
Hanratty Subacromial Brox et al.,27 Haahr et al.,28 Cochrane Collaboration’s Medium quality (best- Function, pain “No significant differences between physiotherapy Low
et al.15 impingement Brox et al.29 tool for assessing risk of evidence synthesis) vs surgical groups were found. Both exercise and
syndrome bias surgery were significantly better than placebo in
reducing pain and improving function; neither
treatment was superior.”15(p.6-8)
Kelly et al.22 Subacromial Brox et al.,27 Haahr et al.,28 Unclear Overall poor (PEDro Function or disability, “No significant differences between physiotherapy Low
impingement Brox et al.,29 Rahme et al.31 scale) pain, strength, range and surgical groups.”22(p.106)“The review has
syndrome of motion shown exercise to be effective to some degree in
the management of subacromial impingement
syndrome. Support for exercise can only be
tentatively accepted because of methodological
flaws in the included studies.”22(p.107)
Braun et al.23 Shoulder Ketola et al.35 Unclear PEDro scale Pain, disability “There is limited evidence from one RCT to Low
impingement indicate that arthroscopic subacromial
decompression surgery may not provide superior
effects compared with a physiotherapeutic
exercise regime.”23(p.282)
Gebremariam Subacromial Brox et al.,27 Haahr et al.,28 Furlan’s 12 quality Low quality (Furlan Function, pain “No evidence was found for the superiority of Low
et al.17 impingement Rahme et al.31 criteria quality criteria) subacromial decompression (arthroscopic or
syndrome open) compared with conservative treatment in
the short, mid, and long term.”17(p.1905)
Kuhn13 Impingement Brox et al.,27 Haahr et al.,28 3-domain list Unclear; Levels 1 and 2 Function or disability, “All studies failed to show statistically significant Critically
syndrome Brox et al.,29 Peters & (randomization, pain, range of differences between the acromioplasty with low
Kohn,30 Rahme et al.31 independent examiner, motion exercise vs exercise alone treatments.”13(p.148)
and follow-up assessed)

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Table 1 (continued )

Risk-of-bias Quality of evidence* AMSTAR

Author Population Studies assessment tool (assessment tool) Outcomes Results or conclusions{ 2 quality

Kromer et al.14 Subacromial Brox et al.27 Haahr et al.,28 PEDro scale Moderate to strong Function or disability, “According to our best-evidence synthesis, Critically
impingement Brox et al.,29 Haahr & (best-evidence pain, range of moderate evidence was found for an equal low
syndrome Andersen34 synthesis) motion, strength effectiveness of physiotherapist-led exercises and
surgery in patients with subacromial impingement
syndrome (SIS), especially in the long
term.”14(p.878)

* Quality of evidence per outcome for individual studies included in each systematic review, according to its authors.
{ According to the authors of the reviews.
AMSTAR 2 = Measurement Tool to Assess Systematic Reviews; GRADE = Grading of Recommendations Assessment, Development and Evaluation; PEDro = Physiotherapy Evidence Database; SIGN = Scottish
Intercollegiate Guidelines Network; CMSG = Cochrane Musculoskeletal Group.
Nazari et al. Conservative versus Surgical Interventions for Shoulder Impingement: An Overview of Systematic Reviews of RCTs
289
Table 2 AMSTAR 2 Ratings for the 15 Selected Systematic Reviews
290

Page Steuri Haik Goldgrub Saltychev et Abdulla Coghlan Dorrestijn Dong Hanratty Kelly Braun Gebremariam Kromer
Domain et al.11 et al.12 et al.16 et al.24 al.21 et al.20 et al.25 et al.18 et al.19 et al.15 et al.22 et al.23 et al.17 Kuhn13 et al.14
1. Research question and Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
inclusion criteria
aligned with PICO
2. A priori protocol Yes No No Partial yes No Yes Yes No No Yes No No No No No
3. Study design selection No No No No No No No Yes No No No No No No Yes
explained
4. Comprehensive search Yes Yes Partial yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Partial yes Yes Yes
5. Duplicate study Yes Yes Yes Yes No Yes Yes Yes Yes No Yes Yes Yes No No
selection
6. Duplicate data Yes Yes Yes Yes No Yes Yes Yes Yes No Yes Yes Yes Yes No
extraction
7. List and justification of Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes No Yes
excluded studies
8. Included studies Yes Yes Yes Yes Yes Yes Yes Partial Partial Yes Yes Yes Partial Yes Yes
described in adequate yes yes yes
detail
9. Satisfactory technique Yes Yes Partial Partial Yes Partial Yes Partial Yes Yes Partial Partial Yes No Partial
for assessment of risk yes yes yes yes yes yes yes
of bias
10. Sources of funding of Yes No No No No No Yes No No No No No No No No
included studies reported
in review
11. If meta-analysis: Yes Yes Not Not Yes Not Yes Not Yes No Not Not Not Not No
justified combination applicable applicable applicable applicable applicable applicable applicable applicable
of data
12. If meta-analysis: risk Yes Yes Not Not Yes Not Yes Not Yes No Not Not Not Not No
of bias of included applicable applicable applicable applicable applicable applicable applicable applicable
studies taken
into account
13. Risk of bias taken Yes Yes Yes Yes Yes Yes Yes Yes No Yes No No No No No
into account in
interpretation
and discussion
14. Satisfactory explanation Yes Yes No No Yes No Yes No Yes No No No No No No
for any heterogeneity
Yes Yes Yes No No No No
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Table 2 (continued )

Page Steuri Haik Goldgrub Saltychev et Abdulla Coghlan Dorrestijn Dong Hanratty Kelly Braun Gebremariam Kromer
Domain et al.11 et al.12 et al.16 et al.24 al.21 et al.20 et al.25 et al.18 et al.19 et al.15 et al.22 et al.23 et al.17 Kuhn13 et al.14
15. Publication bias in Not Not Not Not Not Not Not Not
included studies applicable applicable applicable applicable applicable applicable applicable applicable
assessed
16. Review authors report Yes Yes Yes Yes Yes No Yes No Yes Yes No Yes Yes No No
on any of their own
conflicts of interest
Overall quality rating High Moderate Moderate Moderate Moderate Moderate Moderate Moderate Low Low Low Low Low Critically Critically
low low

Note: Each of the 16 criteria on the AMSTAR 2 checklist are shown for each of the 15 selected systematic reviews. Yes, no, partial yes, and not applicable indicate whether the study satisfied each of these criteria.
AMSTAR 2 = Measurement Tool to Assess Systematic Reviews; PICO = population, intervention, comparison, and outcome.
Nazari et al. Conservative versus Surgical Interventions for Shoulder Impingement: An Overview of Systematic Reviews of RCTs
291
292
clinical outcomes (function, pain, range of motion)
between exercise and surgery among patients with shoul-
der impingement syndrome at the shortest and longest
follow-ups.12 In addition, one SR included moderate-
quality RCTs and showed no differences in outcomes
(function, pain, range of motion) between exercise and
arthroscopic surgery in patients with subacromial pain
syndrome at 6 and 12 months.16
Using the best-evidence synthesis approach, four SRs
included limited- to moderate-quality RCTs and indi-
cated no differences in clinical outcomes (function, pain,
range of motion, strength) between exercise and surgery
in patients with subacromial impingement syndrome at 6
months to 4 years.18,20,21,24 Using the CMSG guidelines,
one SR included silver-level evidence RCTs and showed
no differences in outcomes (function, pain) between
exercise and surgery in patients with impingement syn-
drome at 6 and 12 months.25
Low-quality SRs
We rated five SRs as having low-quality evi-
dence.15,17,19,22,23 Using the best-evidence synthesis
approach, one SR included moderate-quality RCTs and
indicated no differences in outcomes (function, pain)
between exercise and arthroscopic surgery in patients
with subacromial impingement syndrome at 6 and 12
months.15 Using the Furlan quality criteria,17 one SR in-
cluded low-quality RCTs and determined there were no
differences in outcomes (function, pain) between exer-
cise and arthroscopic surgery among patients with suba-
cromial impingement syndrome at short-, mid-, and
long-term follow-up.17
Using the PEDro scale, one SR of poor-quality RCTs
found no differences in outcomes (function, pain, range
of motion, and strength) between physiotherapy (exer-
cise) and surgery in patients with subacromial impinge-
ment syndrome at 6 and 12 months.22 Two SRs, each
with one RCT, showed no differences in outcomes (func-
tion, pain) between exercise and surgery among patients
with shoulder impingement syndrome at 6 and 12
months.19,23 The quality of the individual RCTs in these
SRs was not assessed.19,23
Critically low-quality SRs
We rated two SRs as having critically low-quality evi-
dence.13,14 Using a three-domain list, one SR included Le-
vels 1 and 2 quality RCTs; it indicated no differences in
outcomes (function, pain, range of motion) between
exercise and surgery among patients with impingement
syndrome at up to 4 years after intervention.13 Using the
best-evidence synthesis approach, one SR included mod-
erate- to strong-quality RCTs and indicated no differ-
ences in outcomes (function, pain, range of motion, and
strength) between exercise and surgery among patients
with subacromial impingement syndrome for up to 4
years.14
Physiotherapy Canada, Volume 72, Number 3
DISCUSSION
We conducted an overview of SRs of RCTs to critically
appraise the evidence and establish the current state of
the effectiveness of conservative versus surgical interven-
tions on clinical outcomes among patients with shoulder
impingement. Our overview indicates that the results
from the 15 selected SRs were in line with one another –
stating that there were no differences in clinical out-
comes between supervised exercises and surgery among
patients with shoulder impingement. However, we noted
disparities in their methodological quality. Such dispari-
ties influence the extent to which an accurate and com-
prehensive summary of the results can be provided.
The SRs used various appraisal tools to assess the risk
of bias in the included trials and to summarize the quality
of evidence. We were able to demonstrate that variations
in the appraisal tools used affected the quality of evi-
dence synthesized from the SRs. Haik and colleagues
used the PEDro scale and the GRADE approach to syn-
thesize moderate-quality evidence;16 Kromer and collea-
gues used the PEDro scale and best-evidence synthesis
approach and reported moderate- to strong-quality evi-
dence.14 Both SRs were based on the same RCTs across
the same outcomes. This highlights the variations in the
quality of evidence synthesized depending on the type of
appraisal tool used.
To synthesize the quality of evidence pertaining to
effectiveness, trials must use the Cochrane Collabora-
tion’s tool for assessing risk of bias, along with the
GRADE approach; using other quality scales along with
the GRADE approach is not appropriate.11 Moreover, we
noted a lack of reporting and distinction between assess-
ments of risk of bias and assessments of quality. The
terms were often used interchangeably in the selected
SRs. Quality refers to the degree to which researchers
conduct their study to the highest possible standards,
whereas risk-of-bias assessment pertains to the extent
to which the results of a study should be believed. In
addition, we identified 10 SRs that had appraised individ-
ual clinical trials using quality scales with resulting
scores.13–18,20,22–24 This method has been deemed inap-
propriate because it tends to combine aspects of the
quality of reporting with aspects of conducting trials.
Page and colleagues’ high-quality SR and Steuri and col-
leagues’ moderate-quality SR used identical appraisal
tools to assess quality and risk of bias but were rated dif-
ferently using AMSTAR 2.11,12 This indicates that the
methodological quality used in each SR was not merely
based on the choice of appraisal tools used.
Well-conducted SRs provide the highest level of evi-
dence from which strong inference can be drawn.37–41 In
this overview, we identified 13 SRs that did not report on
the sources of funding for the trials they included. There
is evidence to support the hypothesis that the results of
industry-funded trials tend to favour sponsored products
Nazari et al. Conservative versus Surgical Interventions for Shoulder Impingement: An Overview of Systematic Reviews of RCTs
and that such trials are less likely to be published than
trials that are independently funded.26 Moreover, we
identified 10 SRs without protocol registrations. To
reduce the risk of bias, it is important that review authors
develop, agree on, and register the methods (i.e., protocol
registration) of their SR before they carry it out.26
There have been no other overviews on the effective-
ness of conservative versus surgical interventions in pa-
tients with shoulder impingement. Therefore, we were
unable to compare our findings.
Among patients with shoulder or subacromial
impingement syndrome, shoulder-specific exercises that
aim to enhance muscle strength and flexibility must be
considered the first line of conservative treatment to
improve clinical outcomes. Large-scale, multi-centre,
well-designed RCTs are required to further support these
findings.
This overview had one limitation: it did not include
observational studies, conference papers, posters, or ab-
stracts. This approach potentially contributed to a publi-
cation bias in our search strategy; however, our aim was
to summarize the highest level of evidence available.
CONCLUSIONS
This overview of SRs pooled 15 reviews, ranging from
critically low to high quality, and found that there were
no clinically important or statistically significant dif-
ferences in outcomes between conservative (supervised
exercises) versus surgical interventions (arthroscopic
subacromial decompression) among patients with suba-
cromial impingement syndrome.
KEY MESSAGES
What is already known on this topic
Numerous systematic reviews (SRs) have been pub-
lished on the effectiveness of conservative versus surgical
interventions in patients with shoulder impingement, but
the quality of the evidence synthesized by these SRs var-
ies.
What this study adds
This overview of SRs of randomized controlled trials
summarized, critically appraised, and established the
current state of effectiveness of conservative (with exer-
cise component) versus surgical interventions on clinical
outcomes in patients with shoulder impingement. We
found that shoulder-specific exercises must be consid-
ered the first line of conservative treatment to improve
clinical outcomes.
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Nazari et al. Conservative versus Surgical Interventions for Shoulder Impingement: An Overview of Systematic Reviews of RCTs 295

APPENDIX: SEARCH STRATEGY

Database Search condition No. of results

MEDLINE 1 shoulder impingement 79
2 shoulder impingement syndrome
3 shoulder pain
4 subacromial pain syndrome
5 supraspinatus
6 painful arc syndrome
7 painful arc
8 subacromial pain syndrome
9 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8
10 shoulder surgery
11 arthroscopic
12 subacromial
13 decompression
14 arthroscopic subacromial decompression
15 open subacromial decompression
16 acromioplasty
17 shoulder repair
18 debride
19 shoulder surgical
20 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19
21 conservative
22 exercise
23 physiotherapy
24 physical therapy
25 therapy
26 rehabilitation
27 strengthening exercises
28 stretching exercises
29 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28
30 systematic review
31 9 AND 20 AND 29 AND 30
EMBASE 1 shoulder impingement 47
2 shoulder impingement syndrome
3 shoulder pain
4 subacromial pain syndrome
5 supraspinatus
6 painful arc syndrome
7 painful arc
8 subacromial pain syndrome
9 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8
10 shoulder surgery
11 arthroscopic
12 subacromial
13 decompression
14 arthroscopic subacromial decompression
15 open subacromial decompression
16 acromioplasty
17 shoulder repair

(continued on next page )?

296 Physiotherapy Canada, Volume 72, Number 3

Database Search condition No. of results

18 debride
19 shoulder surgical
20 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19
21 conservative
22 exercise
23 physiotherapy
24 physical therapy
25 therapy
26 rehabilitation
27 strengthening exercises
28 stretching exercises
29 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28
30 systematic review
31 9 AND 20 AND 29 AND 30
CINAHL 1 shoulder impingement 31
2 shoulder impingement syndrome
3 shoulder pain
4 subacromial pain syndrome
5 supraspinatus
6 painful arc syndrome
7 painful arc
8 subacromial pain syndrome
9 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8
10 shoulder surgery
11 arthroscopic
12 subacromial
13 decompression
14 arthroscopic subacromial decompression
15 open subacromial decompression
16 acromioplasty
17 shoulder repair
18 debride
19 shoulder surgical
20 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19
21 conservative
22 exercise
23 physiotherapy
24 physical therapy
25 therapy
26 rehabilitation
27 strengthening exercises
28 stretching exercises
29 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28
30 systematic review
31 9 AND 20 AND 29 AND 30
PubMed 1 shoulder impingement 265
2 shoulder impingement syndrome
3 shoulder pain
4 subacromial pain syndrome
5 supraspinatus
6 painful arc syndrome

(continued on next page )?

Nazari et al. Conservative versus Surgical Interventions for Shoulder Impingement: An Overview of Systematic Reviews of RCTs 297

Database Search condition No. of results

7 painful arc
8 subacromial pain syndrome
9 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8
10 shoulder surgery
11 arthroscopic
12 subacromial
13 decompression
14 arthroscopic subacromial decompression
15 open subacromial decompression
16 acromioplasty
17 shoulder repair
18 debride
19 shoulder surgical
20 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19
21 conservative
22 exercise
23 physiotherapy
24 physical therapy
25 therapy
26 rehabilitation
27 strengthening exercises
28 stretching exercises
29 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28
30 systematic review
31 9 AND 20 AND 29 AND 30