Evidencias en la rehabilitación del hombro doloroso

Evidencias en Rehabilitación del Hombro Doloroso

Ángel León [email protected]!

@Angel_Leon_!

UGC Intercentros-‐Interniveles HHUU de Puerto Real y Puerta del Mar (Cádiz)

EVIGRA 2014 Granada 19-22 Febrero

Presentar las evidencias de mayor calidad y más

actualizadas!

Compartir y difundir!

#Evigra!!@Angel_Leon_!!

Niveles de evidencia!

Nivel I! Evidencia obtenida de estudios diagnós4cos, prospec4vos o ECA de ALTA calidad!

Nivel II! Evidencia obtenida de estudios diagnós4cos, prospec4vos o ECA de BAJA calidad!

Nivel III! Evidencia obtenida de estudios CASOS-‐CONTROLES o RETROSPECTIVOS!

Nivel IV! Evidencia obtenida de SERIES DE CASOS!

Nivel V! Evidencia obtenida de OPINIÓN DE EXPERTOS!

Grados de recomendación!

A! FUERTE! Una mayoría de estudios nivel I!

B! MODERADA! Una mayoría de estudios de nivel II o un único estudio nivel I, apoyan la recomendación !

C! DEBIL! Un solo estudio nivel II o una mayoría de estudios de nivel III y IV apoyan la recomendación !

D! CONFLICTIVA! La recomendación se basa en estos estudios contradictorios !

E! TEÓRICA!Una mayoría de estudios en animales o de cadáveres o estudios de investigación en ciencias básicas apoyan esta conclusión!

F! OPINIÓN DE EXPERTOS! Prácticas basadas en la experiencia clínica!

HOMBRO DOLOROSO!•  Cuadro clínico caracterizado por dolor

localizado a nivel del hombro, en cualquiera de sus 3 articulaciones (glenohumeral, acromioclavicular y esternoclavicular ) y/o tejidos blandos circundantes !

•  Prevalencia estimada: 16% al 34%!

HOMBRO DOLOROSO

PATOLOGÍA EXTRÍNSECA

•  Trastornos cervicales!•  Trastornos nerviosos: radiculopatía,

lesión plexo braquial, síndrome de Parsonnage-Turner o neuralgia amiotro ́fica.!

•  Trastornos inflamatorios: polimialgia reuma ́tica. !

•  Síndrome de Dolor Regional Complejo!

•  Dolor miofascial!•  Lesiones tora ́cicas o costales!•  Dolor referido visceral !

HOMBRO DOLOROSO PATOLOGÍA INTRÍNSECA

HOMBRO DOLOROSO

PATOLOGÍA INTRÍNSECA

!

•  Capsulitis adhesiva!•  Lesiones Manguito!•  Inestabilidad!

!

PATOLOGÍA EXTRÍNSECA

•  Trastornos cervicales!•  Trastornos nerviosos: radiculopatía,

lesión plexo braquial, síndrome de Parsonnage-Turner o neuralgia amiotro ́fica.!

•  Trastornos inflamatorios: polimialgia reuma ́tica. !

•  Síndrome de Dolor Regional Complejo!

•  Dolor miofascial!•  Lesiones tora ́cicas o costales!•  Dolor referido visceral !

CAPSULITIS ADHESIVA!

Health Technology Assessment 2012; Vol. 16: No. 11ISSN 1366-5278

Health Technology AssessmentNIHR HTA programmewww.hta.ac.uk

March 201210.3310/hta16110

Management of frozen shoulder: a systematic review and cost-effectiveness analysis

E Maund, D Craig, S Suekarran, AR Neilson, K Wright, S Brealey, L Dennis, L Goodchild, N Hanchard, A Rangan, G Richardson, J Robertson and C McDaid

Health Technology Assessment 2012; Vol. 16: No.111

ISSN 1366-5278

Abstract

Glossary

List of abbreviations

Executive summaryBackgroundObjectivesMethodsResultsConclusionsFunding

Chapter 1 BackgroundThe decision problemFrozen shoulderDiagnosis and managementPrevious systematic reviewsFocus of the synthesis

Chapter 2 MethodsOverviewReview of clinical effectiveness and cost-effectivenessLiterature searchesInclusion and exclusion criteriaScreening and study selectionData extractionAssessment of risk of biasSynthesisSystematic review of patients’ views of interventions for frozen shoulderAssessment of cost-effectiveness

Chapter 3 ResultsAssessment of clinical effectivenessMixed-treatment comparison resultsPatients’ views of interventions for frozen shoulderEconomic analysesDecision model

Chapter 4 DiscussionPrincipal findingsStrengths and limitations of the reviewImproving the evidence on the effectiveness and cost-effectiveness

Chapter 5 ConclusionsImplications for service provisionSuggested research priorities

AcknowledgementsContribution of authors

References

Appendix 1 Search strategies for effectiveness review 179BIOSIS PreviewsCumulative Index to Nursing and Allied Health Literature (CINAHL)Cochrane Central Register of Controlled Trials (CENTRAL)Clinicaltrials.govCochrane Database of Systematic Reviews (CDSR)Conference Proceedings Citation Index: ScienceDatabase of Abstracts of Reviews of Effects (DARE)EMBASEHealth Management Information Consortium (HMIC)Health Technology Assessment (HTA) databaseLatin American and Caribbean Health Sciences Literature (LILACS)Manual, Alternative and Natural Therapy (MANTIS)NHS Economic Evaluation Database (NHS EED)National Technical Information Service (NTIS)PASCALPhysiotherapy Evidence Database (PEDro)PREMEDLINEScience Citation IndexAdditional quality of life search strategy for information to inform the decision-analytic model

Appendix 2 Search strategy for review of views of people with frozen shoulder 233Cumulative Index to Nursing and Allied Health Literature (CINAHL)MEDLINEPsycINFO

Appendix 3 R code for standard deviation 237

Health Technology Assessment programme

Appendix 4 Quality assessment checklist 245

Appendix 5 List of excluded studies 247

Appendix 6 Study details 263Appendix 6.1 Steroid injectionAppendix 6.2 Sodium hyaluronateAppendix 6.3 Acupuncture Appendix 6.4 Physical therapyAppendix 6.5 Manipulation under anaesthesiaAppendix 6.6 Distension Appendix 6.7 Capsular release

Appendix 7 Data extraction tables 291Appendix 7.1 Steroid injection

Appendix 7.2 Sodium hyaluronateAppendix 7.3 Physical therapyAppendix 7.4 Acupuncture (with or without physical therapy) Appendix 7.5 Manipulation under anaesthesiaAppendix 7.6 Distension Appendix 7.7 Capsular release

Appendix 8 Study quality 369Controlled trialsObservational studies

Appendix 9 WinBUGS code 373

Appendix 10 Mixed-treatment comparison 375Network 1: studies of any intervention (i.e. conservative and invasive) and any qualityNetwork 2: studies of any intervention that were of good or satisfactory quality (i.e. method of randomisation was adequate and outcome assessment was blinded)Network 3: studies of conservative treatments of any qualityNetwork 4: studies of conservative treatments that were of good or satisfactory quality (i.e. method of randomisation was adequate and outcome assessment was blinded)

Appendix 11 Economic evaluation study quality checklist 383

Appendix 12 Economic evaluation data extraction/summary 385

Appendix 13 Resource-use table 387Resource use for the interventions identified from the primary studies included in the review

Appendix 14 Exploratory mapping analysis 389Mapping from SF-36 PCS and MCS onto EQ-5DMapping from pain visual analogue scale onto EQ-5D

Appendix 15 Protocol 403Research protocol 1.11. Research objectives2. Background3. Research methods4. Advisory Group5. Project timetable and milestones6. ReferencesAppendix A Rapid appraisal search to identify systematic reviews, published and in progress, guidelines and ongoing primary researchAppendix B Search strategyAppendix C Quality assessmentCase series quality rating

Clinical Practice Guidelines

MARTIN J. KELLEY, DPT • MICHAEL A. SHAFFER, MSPT • JOHN E. KUHN, MD • LORI A. MICHENER, PT, PhDAMEE L. SEITZ, PT, PhD • TIMOTHY L. UHL, PT, PhD • JOSEPH J. GODGES, DPT, MA • PHILIP W. MCCLURE, PT, PhD

Shoulder Pain and Mobility Deficits: Adhesive CapsulitisClinical Practice Guidelines Linked to the

International Classification of Functioning, Disability, and Health From the Orthopaedic Section

of the American Physical Therapy AssociationJ Orthop Sports Phys Ther 2013;43(5):A1-A31. doi:10.2519/jospt.2013.0302

REVIEWERS: Roy D. Altman, MD • John DeWitt, DPT • George J. Davies, DPT, MEd, MATodd Davenport, DPT • Helene Fearon, DPT • Amanda Ferland, DPT • Paula M. Ludewig, PT, PhD • Joy MacDermid, PT, PhD

James W. Matheson, DPT • Paul J. Roubal, DPT, PhD • Leslie Torburn, DPT • Kevin Wilk, DPT

For author, coordinator, contributor, and reviewer affiliations, see end of text. Copyright ©2013 Orthopaedic Section, American Physical Therapy Association (APTA), Inc, and the Journal of Orthopaedic & Sports Physical Therapy. The Orthopaedic Section, APTA, Inc, and the Journal of Orthopaedic & Sports Physical Therapy consent to the reproduction and distribution of these guidelines for educational purposes. Address correspondence to: Joseph Godges, DPT, ICF Practice Guidelines Coordinator, Orthopaedic Section, APTA, Inc, 2920 East Avenue South, Suite 200, La Crosse, WI 54601. E-mail: [email protected]

RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A2

INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A3

METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A4

CLINICAL GUIDELINES: Impairment/Function-Based Diagnosis . . . . . . . . . . . . . . . . . . A6

CLINICAL GUIDELINES:Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A14

CLINICAL GUIDELINES: Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A16

SUMMARY OF RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A26

AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS . . . . . . A27

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A28

��*XLGHOLQHV�LQGG�� 30

Definición!

Restricción funcional del balance articular pasivo y activo del hombro, sin lesiones remarcables en estudios radiográficos, excepto por la posible presencia de osteopenia o tendinosis cálcica.!

J Shoulder Elbow Surg. 2011 Mar;20(2):322-5. Frozen shoulder: a consensus definition. Zuckerman JD, Rokito A.!

Clasificación!

A.  PRIMARIO!

B.  SECUNDARIO:!

A.  Intrínseco: !–  Ej.: Tendinopatía del manguito, Tendinosis bicipital, Tendinopatía cálcica!

B.  Extrínseco:!–  Cx mama, Patología cervical, fractura previa, ACV, etc.!

C.  Sistémico:!–  Ej.: DM, hipotiroidismo, etc.!

Factores de riesgo!

Richard J Murphy and Andrew J Carr Shoulder pain Clinical Evidence 2010 !

q Sexo femenino

q Edad avanzada q Trauma4smo de hombro

q Cirugía q Diabetes q Trastornos cardiorrespiratorios q Accidente cerebrovascular q Enfermedad del 4roides

Hª natural!1.  Congelación (FREEZING)!–  Aumento progresivo del dolor y disminución de la

amplitud de movimiento. 6 semanas a 9 meses.!

2.  Congelado (FROZEN)!–  Mejora el dolor, pero la rigidez permanece. 4 a 6

meses.!

3.  Deshielo (THAWING)!–  Mejoría lenta de la movilidad. 6 meses 3 años.!

Diagnóstico!

Exploración física!

Diagnóstico fundamentalmente clínico:!– Perdida BA activo y pasivo!– Mayor afectación rotaciones (especialmente

RE)!– Patrón capsular a la exploración.!

J Shoulder Elbow Surg. 2011 Apr;20(3):502-14. doi: 10.1016/j.jse.2010.08.023. Epub 2010 Dec 16.Current review of adhesive capsulitis.Hsu JE, Anakwenze OA, Warrender WJ,

Abboud JA.!

Diagnóstico por imagen!•  No indicado de rutina.!•  Signos RMN y artroRMN:!

–  Estrechamiento lig. Coracohumeral (también en ecografía) !

–  Contracción capsular: disminución volumen!

–  Estrechamiento a nivel receso axilar.!

•  PLoS One. 2011;6(12):e28704. MRI findings for frozen shoulder evaluation: is the thickness of the coracohumeral ligament a valuable diagnostic tool?Li JQ, Tang et al!

•  J Shoulder Elbow Surg. 2011 Apr;20(3):502-14. doi: 10.1016/j.jse.2010.08.023. Epub 2010 Dec 16.Current review of adhesive capsulitis.Hsu JE, Anakwenze OA, Warrender WJ, Abboud JA.!

Tratamiento!

Esteroides orales!

Proporcionan beneficios significativos a corto plazo ( < 6 semanas) del dolor, el arco de movilidad del hombro y la función. !!

•  Maund E, et al . Health Technol Assess. 2012;16(11):1-264 Management of frozen shoulder: a systematic review and cost-effectiveness analysis.!

!

II!

Infiltraciones esteroides!

•  Beneficios significativos a corto plazo y medio plazo ( < 6 semanas) del dolor, BA, función y discapacidad.!

•  No diferencias significativas en la Calidad de Vida.!

•  Más efectivo que la FT a corto y largo plazo !•  Combinada con FT se añade beneficio a los

tratamientos individualizados.!

•  Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Maund E, et al . Health Technol Assess. 2012;16(11):1-264 !

•  Shoulder pain and mobility deficits: Adhesive Capsulitis. Kelley et al. J Orthop Sport Phys Ther 2013;43(5):A1-A31!

A!

Infiltraciones hialurónico!

•  3 ECA !•  Mejora el BA, función y dolor a corto plazo. !•  Sus resultados son similares a los de la

infiltración con corticoides!•  Alto riesgo de sesgo!

•  Maund E, et al . Health Technol Assess. 2012;16(11):1-‐264 Management of frozen shoulder: a systema4c review and cost-‐effec4veness analysis.

D!

Acupuntura!

•  3 ECA baja calidad (sólo 1 control con placebo)!

•  Reducción del dolor Vs placebo (<4 semanas)!

•  Importante heterogeneidad!•  Alto riesgo de sesgo!


No pruebas suficientes de

eficacia !

III!

Laser!

•  Eslamian F, Shakouri SK, Ghojazadeh M, Nobari OE, Eftekharsadat B. Effects of low-level laser therapy in combination with physiotherapy in the management of rotator cuff tendinitis. Lasers Med Sci. 2012 Sep;27(5):951-8. doi:10.1007/10103-011-1001-3.!

•  M M Favejee, B M A Huisstede, B W Koes Frozen shoulder: the effectiveness of conservative and surgical interventions—ti–56. doi:10.1136/bjsm.2010.071431!

•  Mejoría significativa a corto plazo del dolor y función.!

•  No diferencias significativas en el Balance Articular !

!•  Conflicto de Intereses ?!

I!

Fisioterapia!

•  12 ECA que comparan distintas técnicas de tratamiento.!

•  Importante heterogeneidad!•  Mayor evidencia de la onda

corta y de movilizaciones de alto grado (Grados 3-4 de Maitland)!

•  Resultados inferiores a corto plazo que la infiltración!



C!

Ejercicio!

•  5 ECA.!•  No definición intensidad, duración,

frecuencia etc!•  Sólo uno define ejercicios!•  Instruir a pacientes en ejercicios de

estiramiento específicos. La intensidad debe ser determinada según estado inicial del paciente.!

B!



Bloqueo del n. supraescapular!

•  Beneficios significativos a corto plazo ( 3 meses) del dolor !

•  Los resultados mejoran cuando se aplica con técnica guiada electromiograficamente vs guía anatómica. !

•  Mayor mejoría del dolor y BA que con infiltraciones intrarticulares !

M M Favejee, B M A Huisstede, B W Koes Frozen shoulder: the effectiveness of conservative and surgical interventions—ti–56. doi:10.1136/bjsm.2010.071431!

II!

Bloqueo del n. supraescapular!

•  Beneficios significativos a corto plazo ( 3 meses) del dolor !

•  Los resultados mejoran cuando se aplica con técnica guiada electromiograficamente vs guía anatómica. !

•  Mayor mejoría del dolor y BA que con infiltraciones intrarticulares !

M M Favejee, B M A Huisstede, B W Koes Frozen shoulder: the effectiveness of conservative and surgical interventions—ti–56. doi:10.1136/bjsm.2010.071431!

PENDIENTES A

CTUALIZACIÓ

N DE

LA COCHRANE

II!

Radiofrecuencia!

•  Series de casos!•  Mejoría del dolor y del BA!•  Resultados se mantienen a

medio plazo!

Huang CC, Tsao SL, Cheng CY, Hsin MT, Chen CM. Treating frozen shoulder with ultrasound-guided pulsed mode radiofrequency lesioning of the suprascapular nerve: two cases. Pain Med. 2010 Dec;11(12):1837-40. doi:!10.1111/j.1526-4637.2010.00970.x. Epub 2010 Oct 28. PubMed PMID: 21040432.!

IV!

Manipulación bajo anestesia!

•  No diferencias entre la manipulación bajo anestesia y tratamientos conservadores (RHB, infiltraciones…)!

•  Importantes limitaciones:!–  Ensayos muy heterogéneos. !–  Recogida de resultados!

Health Technol Assess. 2012;16(11):1-264. doi: 10.3310/hta16110.!Management of frozen shoulder: a systematic review and cost-effectiveness analysis.!Maund E, Craig D, Suekarran S, Neilson A, Wright K, Brealey S, Dennis L, Goodchild L, Hanchard N, Rangan A, Richardson G, Robertson J, McDaid C!

C!

Hidrodilatación!•  1 ECA y casos controles!•  No diferencia significativa con

la manipulación bajo anestesia.!

•  No diferencia al comparar con corticoides sólos!


•  Quraishi NA, Johnston P, Bayer J, Crowe M, Chakrabarti AJ. Thawing the frozen shoulder. A randomised trial comparing manipulation under anaesthesia with hydrodilatation. J Bone Joint Surg Br. 2007 Sep;89(9):1197-200. PubMed PMID:17905957.!

•  Tveitå EK, Tariq R, Sesseng S, Juel NG, Bautz-Holter E. Hydrodilatation, corticosteroids and adhesive capsulitis: a randomized controlled trial. BMC Musculoskelet Disord. 2008 Apr 19;9:53. doi: 10.1186/1471-2474-9-53. PubMed PMID:18423042; PubMed Central PMCID: PMC2374785!

III!

Distensión artrográfica!

Rev. COCHRANE:!–  Existe EVIDENCIA MODERADA

de que proporciona beneficios a corto plazo para el dolor, la amplitud de movimiento y la función en la capsulitis adhesiva. !

–  Los resultados mejoran si se realiza fisioterapia posteriormente.!


•  Buchbinder R, Green S, Youd JM, Johnston RV, Cumpston M. Distensión artrográfica para la capsulitis adhesiva En: La Biblioteca Cochrane Plus, 2008 Número 4!

Rev. HTA: •  No existe evidencia consistente (Riesgo de sesgo en la recogida de resultados)

D!

Liberación capsular! •  1 Casos-Control (y 2 series

de casos)!

•  Poco beneficio de la liberación capsular +/-Manipulación bajo anestesia. !

•  Grant JA, Schroeder N, Miller BS, Carpenter JE. Comparison of manipulation and arthroscopic capsular release for adhesive capsulitis: a systematic review. J Shoulder Elbow Surg. 2013 Aug;22(8):1135-45. doi: 10.1016/j.jse.2013.01.010. Epub 2013 Mar 17!


III!

Movilización bajo anestesia/ Distensión artrográfica / Liberación capsular!

Bloqueo n. Supraescapular / Hidrodilatación!

Infiltración con esteroides + FT!

Laser / Onda corta! Ejercicio terapéutico! Movilizaciones Alto Grado!

1ª Infiltración con esteroides + Programa domiciliario!

Propuesta tratamiento!

PATOLOGÍA DEL MANGUITO!

•  Pinzamiento mecánico del tendón del manguito rotador debajo de la parte anteroinferior del acromion, por uno o más de los diferentes componentes del arco acromial: acromion, articulación acromioclavicular, ligamento acromiocoracoideo y apófisis coracoides (Neer 1983)!

Diagnóstico!

Exploración física!SYSTEMATIC REVIEW

Diagnostic Accuracy of Clinical Tests for Subacromial

Impingement Syndrome: A Systematic Review and

Meta-Analysis

Marwan Alqunaee, RCSI, Rose Galvin, BSc (Physio), PhD, Tom Fahey, MD, FRCGP

ABSTRACT. Alqunaee M, Galvin R, Fahey T. Diagnostic

accuracy of clinical tests for subacromial impingement syn-

drome: a systematic review and meta-analysis. Arch Phys Med

Rehabil 2012;93:229-36.

Objective: To examine the accuracy of clinical tests for

diagnosing subacromial impingement syndrome (SIS).

Data Sources: A systematic literature search was conducted

in January 2011 to identify all studies that examined the diag-

nostic accuracy of clinical tests for SIS. The following search

engines were used: Cochrane Library, EMBASE, Science Di-

rect, and PubMed.

Study Selection: Two reviewers screened all articles. We

included prospective or retrospective cohort studies that exam-

ined individuals with a painful shoulder, reported any clinical

test for SIS, and used arthroscopy or open surgery as the

reference standard. The search strategy yielded 1338 articles of

which 1307 publications were excluded based on title/abstract.

Sixteen of the remaining 31 articles were included. The

PRISMA (preferred reporting items for systematic reviews and

meta-analyses) guidelines were followed to conduct this

review.Data Extraction: The number of true positives, false posi-

tives, true negatives, and false negatives for each clinical test

were extracted from relevant studies, and a 2!2 table was

constructed. Studies were combined using a bivariate random-

effects model. Heterogeneity was assessed using the variance

of logit-transformed sensitivity and specificity.

Data Synthesis: Ten studies with 1684 patients are included

in the meta-analysis. The Hawkins-Kennedy test, Neer’s sign,

and empty can test are shown to be more useful for ruling out

rather than ruling in SIS, with greater pooled sensitivity esti-

mates (range, .69–.78) than specificity (range, .57–.62). A

negative Neer’s sign reduces the probability of SIS from 45%

to 14%. The drop arm test and lift-off test have higher pooled

specificities (range, .92–.97) than sensitivities (range, .21–.42),

indicating that they are more useful for ruling in SIS if the test

is positive.

Conclusions: This systematic review quantifies the diagnostic

accuracy of 5 clinical tests for SIS, in particular the lift-off test.

Accurate diagnosis of SIS in clinical practice may serve to

improve appropriate treatment and management of individuals

with shoulder complaints.

Key Words: Meta-analysis; Rehabilitation; Sensitivity and

specificity; Subacromial impingement syndrome.

© 2012 by the American Congress of Rehabilitation

Medicine

SHOULDER PAIN IS the third most common musculosk-

eletal consultation in primary care, and second most com-

mon cause of referrals to orthopedic and sports medicine clin-

ics.1,2 The differential diagnosis of conditions that cause

shoulder pain is a challenging and complex area of musculo-

skeletal practice. Subacromial impingement syndrome (SIS) is

the most frequent cause of shoulder pain. SIS is a clinical

syndrome that indicates pain and pathology relating to the

subacromial bursa and rotator cuff tendons within the subacro-

mial space. The 3 stages of SIS are subacromial bursitis,

partial-thickness and full-thickness rotator cuff tears.3 The

cause of SIS is considered to be multifactorial, with both

extrinsic and intrinsic factors involved in its pathogenesis.4 The

primary factors relating to the intrinsic theory are muscle

overload and weakness, shoulder overuse and repetitive tissue

microtrauma, and degeneration of the rotator cuff. The key

elements of the extrinsic hypothesis are shape of the acromion,

glenohumeral instability, altered scapulothoracic rhythm, os

acromiale, and degeneration of the acromioclavicular joint.5,6

Clinicians have traditionally relied on a clinical examination

comprising a subjective history and physical examination, fol-

lowed by various clinical tests to diagnose SIS. Numerous

clinical tests have been described to evaluate the presence of

impingement syndrome and to determine the integrity of the

individual components of the rotator cuff.7 These tests can be

broadly classified as impingement or pain provocation tests and

rotator cuff strength tests. Impingement tests are designed to

reproduce symptoms or pain by compressing the greater tuber-

osity against the acromion.8,9 Rotator cuff strength tests assess

the integrity of the individual rotator cuff tendons and their

respective musculotendinous units. Table 1 contains the com-

From the HRB Centre for Primary Care Research, Department of General Practice,

Royal College of Surgeons in Ireland, Dublin, Republic of Ireland.

Supported by the Health Research Board (HRB) of Ireland through the HRB Centre

for Primary Care Research (grant no. HRC/2007/1).

No commercial party having a direct financial interest in the results of the research

supporting this article has or will confer a benefit on the authors or on any organi-

zation with which the authors are associated.

Reprint requests to Rose Galvin, BSc (Physio), PhD, HRB Centre for Primary Care

Research, Dept of General Practice, Royal College of Surgeons in Ireland, 123 St.

Stephens Green, Dublin 2, Republic of Ireland, e-mail: [email protected].

0003-9993/12/9302-00341$36.00/0

doi:10.1016/j.apmr.2011.08.035

List of Abbreviations

CI confidence interval

LR likelihood ratio

PRISMA preferred reporting items for systematic

reviews and meta-analyses

QUADAS quality assessment of diagnostic

accuracy studies

ROC receiver operating characteristic

SIS subacromial impingement syndrome

229

Arch Phys Med Rehabil Vol 93, February 2012

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Database of Abstracts of Reviews of Effects (DARE)Produced by the Centre for Reviews and Dissemination

Copyright © 2014 University of York

Page: 1 / 3

Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. Database of Abstracts of Reviews of Effects (DARE). 25 Abril 2013!

Diagnostic accuracy of clinical tests for!subacromial impingement syndrome: a systematic review and meta-analysis. Alqunaee M, Galvin R, Fahey T. Arch!Phys Med Rehabil. 2012 Feb;93(2):229-36. !

Physical tests for shoulder!impingements and local lesions of bursa, tendon or labrum that may accompany!impingement. Hanchard NC, et al. Cochrane Database Syst Rev. 2013 Apr 30;4:CD007427. !

Physical tests for shoulder impingements and local lesions ofbursa, tendon or labrum that may accompany impingement(Review)

Hanchard NCA, Lenza M, Handoll HHG, Takwoingi Y

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library

2013, Issue 4

http://www.thecochranelibrary.com

Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement (Review)

Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Alto Valor Predictivo Negativo!

S. Subacromial!

Alta Sensibilidad!

Hawkins-Kennedy !Signo del Neer !Empty-Can (Jobe)!

Alto Valor Predictivo Positivo!

Alta Especificidad!

Drop Arm!Lift off Test!

Desgarro de subescapular !–  Internal rotation lag sign: sensibilidad muy

alta 97 %!– Lift-Off Test: alta especificidad!

Patología del Infraespinoso: !– Patte: tenía una especificidad muy alta 95 %,

pero también de alta sensibilidad 94%!– Rot externa contra resistencia: una

especificidad del 99% y la sensibilidad de 96% !

Patología del Supraespinoso: !– No había ninguna prueba individual con

propiedades tan altas!– Empty Can Test (Jobe) puede ser útil para

descartar la lesión con sensibilidad de 94%!

Diagnóstico por Imagen!

SENSIBILIDAD! ESPECIFICIDAD!

RMN! ECO! A-RM! RMN! ECO! A-RM!

ROTURAS COMPLETAS! 0,94! 0,92! 0,94! 0,93! 0,93! 0,92!

Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NCA, Faloppa F. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD009020. DOI: 10.1002/14651858.CD009020.pub2.!

• No hubo diferencia estadís4camente significa4va en el rendimiento de diagnós4co para la detección de desgarros de espesor completo al comparar la RM, ecograaa y artroRM.

SENSIBILIDAD! ESPECIFICIDAD!

RMN! ECO! A-RM! RMN! ECO! A-RM!

ROTURAS PARCIALES! 0,74! 0,52! *! 0,93! 0,93! *!

Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NCA, Faloppa F. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD009020. DOI: 10.1002/14651858.CD009020.pub2.!

•  El rendimiento diagnós4co de la resonancia magné4ca y de la ecograaa puede ser similar, pero disminuye su sensibilidad para la detección de desgarros de espesor parcial.

* No posible metaanálisis


Ramon P. Ottenheijm, Mariëtte J. Jansen, J. Bart Staal, Ann van den Bruel, René E. Weijers, Rob A. de Bie, Geert-Jan Dinant, Accuracy of Diagnostic Ultrasound in Patients With Suspected Subacromial Disorders: A Systematic Review and Meta-Analysis . Arch Phys Med Rehabil Vol 91, October 2010!

SENSIBILIDAD! ESPECIFICIDAD!BURSITIS

SUBACROMIAL! 0,79-0,81! 0.94 - 0 .98!

TENDINOPATÍAS! 0,67-0,93! 0.88 - 1.00!

T. CALCIFICANTE! 1! 0.85 - 0.98!


Tratamiento!

REVIEW ARTICLE (META-ANALYSIS)

Subacromial Impingement Syndrome: Effectivenessof Pharmaceutical InterventionseNonsteroidalAnti-Inflammatory Drugs, Corticosteroid, or OtherInjections: A Systematic Review

Renske van der Sande, MD,a Willem D. Rinkel, MSc,b Lukas Gebremariam, MD,a

Elaine M. Hay, FRCP, MD,c Bart W. Koes, PhD,a Bionka M. Huisstede, PhDa,b

From the Departments of aGeneral Practice and bRehabilitation Medicine, Erasmus MC e University Medical Center, Rotterdam, TheNetherlands; and cthe Arthritis Research Campaign National Primary Care Centre, Keele University, Keele, United Kingdom.

AbstractObjective: To present an evidence-based overview of the effectiveness of pharmaceutical interventions, including nonsteroidal anti-inflammatorydrugs, corticosteroid injections, and other injections, used to treat the subacromial impingement syndrome (SIS). An overview can help physiciansselect the most appropriate pharmaceutical intervention, and it can identify gaps in scientific knowledge.Data Sources: The Cochrane Library, PubMed, Embase, PEDro, and CINAHL databases.Study Selection: Two reviewers independently selected relevant reviews and randomized clinical trials.Data Extraction: Two reviewers independently extracted the data and assessed the methodologic quality.Data Synthesis: A best evidence synthesis was used to summarize the results. Three reviews and 5 randomized clinical trials were included.Although we found limited evidence for effectiveness in favor of 2 sessions with corticosteroid injections versus 1 session, for the effectiveness ofcorticosteroid injections versus placebo, nonsteroidal anti-inflammatory drugs, or acupuncture, only conflicting and no evidence for effectivenesswas found. Moderate evidence was found in favor of immediate release oral ibuprofen compared with sustained-released ibuprofen in the short-term. Also, moderate evidence for effectiveness was found in favor of glyceryltrinitrate patches versus placebo patches in the short-term and midterm. Furthermore, injections with disodium ethylene diamine tetraacetic acid plus ultrasound with ethylene diamine tetraacetic acid gel weremore effective (moderate evidence) than was placebo treatment in the short- and long-term.Conclusions: This article presents an overview of the effectiveness of pharmaceutical interventions for SIS. Some treatments seem to bepromising (moderate evidence) to treat SIS, but more research is needed before firm conclusions can be drawn.Archives of Physical Medicine and Rehabilitation 2013;94:961-76

ª 2013 by the American Congress of Rehabilitation Medicine

Musculoskeletal disorders of the shoulder, including tendinitisand bursitis, are difficult to differentiate in clinical practice. Inthe Complaints of the Arm, Neck, and/or Shoulder (CANS) model,the term subacromial impingement syndrome (SIS) is used for therotator cuff syndrome, tendonosis of the Musculus infraspinatus,Musculus supraspinatus, and Musculus subscapularis, and bursitisin the shoulder area.1 More than 50% of the patients suffering fromchronic CANS reported complaints of the shoulder.2 The relation

between shoulder complaints and work-related factors, such asrepetitivework, working with the hand above the shoulder, and highpsychosocial job demands, has been found positive byseveral authors.3

In general practice, SIS is the most frequently reported diag-nosis of the shoulder, with a cumulative incidence of 5 per 1000patients per year.4 Patients with SIS are characterized by painlocalized in the shoulder that is exacerbated when performingoverhead activities.5 The first step in treatment for SIS bya general practitioner often includes an analgesic.6 Also, corti-costeroid injections are an often-used intervention in primarycare.7 New treatment modalities such as tenoxicam injections8

No commercial party having a direct financial interest in the results of the research supporting

this article has or will confer a benefit on the authors or on any organization with which the authors

are associated.

0003-9993/13/$36 - see front matter ª 2013 by the American Congress of Rehabilitation Medicinehttp://dx.doi.org/10.1016/j.apmr.2012.11.041

Archives of Physical Medicine and Rehabilitationjournal homepage: www.archives-pmr.org

Archives of Physical Medicine and Rehabilitation 2013;94:961-76

Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical Interventions–Nonsteroidal Anti-Inflammatory Drugs, Corticosteroid, or Other Injections: A Systematic Review!Renske van der Sande, et al. Archives of physical medicine and rehabilitation 1 May 2013!

AINES!Múl4ples ECA: •  Diclofenaco •  Flurbiprofeno •  Naproxeno •  Celecoxib •  Ibuprofeno •  Ibupfofeno liberación

sostenida


Celecoxib único que compara con placebo!

II!

AINES!Múl4ples ECA: •  Diclofenaco •  Flurbiprofeno •  Naproxeno •  Celecoxib •  Ibuprofeno •  Ibupfofeno liberación

sostenida


Celecoxib único que compara con placebo!

PENDIENTES A

CTUALIZACIÓ

N DE

LA COCHRANE

II!

Otros fármacos orales!

•  No disponemos de ensayos cli ́nicos aleatorizados sobre AINEs tópicos, Paracetamol y Opioides!

•  Guías Práctica clínica: Recomendado el control del dolor con analgésicos.!

III!

Parches de nitroglicerina!

Estudio basado en 1 ECA!•  Parche NTG + RHB!•  Placebo + RHB!

•  Hay débil evidencia de la efectividad de los parches de nitroglicerina Vs placebo a corto (12 semanas) y medio plazo (24 semanas)!

•  Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical Interventions–Nonsteroidal Anti-Inflammatory Drugs, Corticosteroid, or Other Injections: A Systematic Review Renske van der Sande, et al. Archives of physical medicine and rehabilitation 1 May 2013 (volume 94 issue 5 Pages 961-976 DOI: 10.1016/j.apmr.2012.11.041)!

III!

Infiltraciones esteroides Patología del manguito!

•  5 ECAS !

•  Mejoría significativa del dolor Vs placebo!•  No diferencias al comparar con TENS u Onda

corta!

•  Rabini A, et al Effects of local microwave diathermy on shoulder pain and function in patients with rotator cuff tendinopathy in comparison to subacromial corticosteroid injections: a single-blind randomized trial. J Orthop Sports Phys Ther. 2012 Apr;42(4):363-70. doi: 10.2519/jospt.2012.378722281781. Epub 2012 Jan 25. !

•  Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical Interventions–Nonsteroidal Anti-Inflammatory Drugs, Corticosteroid, or Other Injections: A Systematic Review. Renske van der Sande, et al. Archives of physical medicine and rehabilitation 1 May 2013. !

II!

Infiltraciones esteroides S. Subacromial!

•  7 ECAS (4 alta calidad) = empate a 2.!

•  Evidencia conflictiva sobre la efectividad de las inyecciones con corticoides Vs placebo a corto (4 semanas) y medio plazo (12 semanas)!


D!

Infiltraciones AINES S. Subacromial!

•  3 ECAS.!

•  No diferencias significativas en la infiltración con corticoide Vs AINE. !

•  No diferencias entre infiltración combinada corticoide + AINE!

!


II!

¿Infiltraciones ecoguiadas?!

Bloom JE, Rischin A, Johnston RV, Buchbinder R. Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD009147. DOI: 10.1002/14651858.CD009147.pub2.!

II!

•  Pruebas de calidad moderada indican que no hay ninguna diferencia en el dolor o la función !

•  Pruebas de calidad moderada sugiere que hay probablemente ninguna diferencia en la incidencia de eventos adversos!

Plasma rico en plaquetas!

No evidencia del beneficio del PRP en patología del manguito.!

II!

Arthroscopy. 2012 Nov;28(11):1718-27. doi: 10.1016/j.arthro.2012.03.007. Epub 2012 Jun 12.!The role of platelet-rich plasma in arthroscopic rotator cuff repair: a systematic review with quantitative synthesis.!Chahal J, Van Thiel GS, Mall N, Heard W, Bach BR, Cole BJ, Nicholson GP, Verma NN, Whelan DB, Romeo AA.!

Cochrane Database Syst Rev. 2013 Dec 23;12:CD010071. doi: 10.1002/14651858.CD010071.pub2.!Platelet-rich therapies for musculoskeletal soft tissue injuries.!Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC.!

Laser!

•  Yavuz F, Duman I, Taskaynatan MA, Tan AK. Low-level laser therapy versus ultrasound therapy in the treatment of subacromial impingement syndrome: A Rndomized clinical trial. J Back Musculoskelet Rehabil. 2013 Dec 17. [Epub ahead of print] PubMed PMID: 24346151!

•  Eslamian F, Shakouri SK, Ghojazadeh M, Nobari OE, Eftekharsadat B. Effects of low-level laser therapy in combination with physiotherapy in the management of rotator cuff tendinitis. Lasers Med Sci. 2012 Sep;27(5):951-8. doi:10.1007/10103-011-1001-3!

•  Tendinopatía del manguito: Mejora el dolor a corto plazo Vs placebo y Ultrasonido.!

•  S. Subacromial: evidencia conflictiva!

II!

Magnetoterapia!

•  Tendinopatía cálcica y SIS a corto y medio plazo!

•  Significificación clínica débil!•  1ECA No efecto en otros

procesos!

Pulsed electromagnetic field and exercises in patients with shoulder impingement syndrome: a randomized, double-blind, placebo-controlled clinical trial. Galace de Freitas D, Marcondes FB, Monteiro RL, Rosa SG, Maria de Moraes Barros Fucs P, Fukuda TY. Arch Phys Med Rehabil. 2014 Feb;95(2):345-52.!

II!

Ultrasonidos!

• Evidencia conflictiva de los US Vs placebo a corto plazo. !• No evidencia a medio plazo.!

Subacromial impingement syndrome—effectiveness of physiotherapy and manual therapy. Lukas Gebremariam, et al. Br J Sports Med 2013;0:1–8. doi:10.1136/bjsports-2012-091802 !!

D!

Iontoforesis ac. acético!

Evidencia moderada de NO eficacia en la reabsorción de calcio.!

II!

Ciccone CD. Does acetic acid iontophoresis accelerate the resorption of calcium deposits in calcific tendinitis of the shoulder? Phys Ther. 2003 Jan;83(1):68-74. PubMed PMID: 12495407.!

Ondas de choque!•  Tendinopatía

calcificante: Son mas efectivas que placebo para mejorar el dolor, la calcificación y la función. !

•  Tendinopatía no calcificante: no son eficaces !

Clinical improvement and resorption of calcifications in calcific tendinitis of the shoulder after shock wave therapy at 6 months' follow-up: a systematic review and meta-analysis.!Ioppolo F, Tattoli M, Di Sante L, Venditto T, Tognolo L, Delicata M, Rizzo RS, Di Tanna G, Santilli V.!Arch Phys Med Rehabil. 2013 Sep;94(9):1699-706. doi: 10.1016/j.apmr.2013.01.030. Epub 2013 Mar 13.!!

I!

Kinesio tape!

Actualmente no existe evidencia para apoyar el uso de kionesio tape en la práctica clínica.!

Physiother Theory Pract. 2013 May;29(4):259-70. doi: 10.3109/09593985.2012.731675. Epub 2012 Oct 22.!The clinical effects of Kinesio® Tex taping: A systematic review.!Morris D, Jones D, Ryan H, Ryan CG.!

II!

Ejercicio!•  Hasta 19 ECA analizados!•  Es necesario estandarizar y

describir los protocolos de tratamiento.!

•  Son necesarios estudios de mayor calidad metodológica.!

II!

The effectiveness of physiotherapy exercises in subacromial impingement syndrome: a systematic review and meta-analysis.!Hanratty CE, et al. Database of Abstracts of Reviews of Effects (DARE) Septiembre 2013!!

Ejercicio!•  Reduce el dolor!•  Aumenta la Fuerza.!•  Mejora la Función (autopercibida)!•  Mejora la Calidad de Vida !•  Los ejercicios domiciliarios son tan

efectivos como los supervisados por fisioterapeutas !

II!

The effectiveness of physiotherapy exercises in subacromial impingement syndrome: a systematic review and meta-analysis.!Hanratty CE, et al. Database of Abstracts of Reviews of Effects (DARE) Septiembre 2013!!

Radiofrecuencia!•  4 ECA !•  Mejoría significativa del dolor!•  Resultados se mantienen a medio

plazo!

II!

Cirugía!No diferencias en los resultados en el dolor y la función del hombro entre la actitud conservadora y quirúrgica!

Clin J Sport Med. 2013 Sep;23(5):406-7. doi: 10.1097/01.jsm.0000433152.74183.53.!Is there evidence in favor of surgical interventions for the subacromial impingement syndrome?!Tashjian RZ.!

I!

Cirugía!

•  No diferencias entre Cirugia abierta, artroscópica o “mini-open”!

•  No diferencias entre fijación “single-row” o “double-row”.!

Clin J Sport Med. 2013 Sep;23(5):406-7. doi: 10.1097/01.jsm.0000433152.74183.53.!Is there evidence in favor of surgical interventions for the subacromial impingement syndrome?!Tashjian RZ.!

II!

Seida J, et al. Comparative Effectiveness of Nonoperative and Operative Treatment for Rotator Cuff Tears. Comparative Effectiveness Review No. 22. (Prepared by the University of Alberta Evidence-based Practice Center) AHRQ 2010.!

Descompresión subacromial!

Programa Individual!

Ejercicio! Terapia manual!

Programa Grupal!

Ejercicio terapéutico!

AINES +/- ANALGÉSICOS!+ Programa domiciliario!

Intervencionismo!

Radiofrecuencia! Artroscopia!

Tto individual!

Ondas de choque! Magnetoterapia ?!

Infiltración + Ejercicio Terapéutico!

AINES +/ LASER!+ Programa domiciliario!

Propuesta tratamiento!S. Subacromial puro! Tendinopatía (incluida cálcica)!

INESTABILIDAD!

La luxación de hombro representa casi el 50% de todas las luxaciones articulares. !! Son anteriores en 90-98% de los casos!

•  Inestabilidad de hombro. Scott Welsh et al. Actualización Medscape Septiembre 2012!

•  Consensus statement on shoulder instability. Arthroscopy. 2010 Feb;26(2):249-55. Bak K, Wiesler ER, Poehling GG; ISAKOS Upper Extremity Committee.!

Diagnóstico!

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Database of Abstracts of Reviews of Effects (DARE)Produced by the Centre for Reviews and Dissemination

Copyright © 2014 University of York

Page: 1 / 3

Which physical examina4on tests provide clinicians with the most value when examining the shoulder? Update of a systema4c review with meta-‐analysis of individual tests. Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. Database of Abstracts of Reviews of Effects (DARE). 25 Abril 2013

Physical tests for shoulder!impingements and local lesions of bursa, tendon or labrum that may accompany!impingement. Hanchard NC, et al. Cochrane Database Syst Rev. 2013 Apr 30;4:CD007427. !

Physical tests for shoulder impingements and local lesions ofbursa, tendon or labrum that may accompany impingement(Review)

Hanchard NCA, Lenza M, Handoll HHG, Takwoingi Y

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library

2013, Issue 4

http://www.thecochranelibrary.com

Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement (Review)

Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Lesiones del Labrum (sup): Test de compresión pasiva con una sensibilidad del 89%, especificidad 85%!

Inestabilidad anterior: Test de aprehesión con una sensibilidad del 65%, especificidad 95%!

Inestabilidad anterior: Test de la sorpresa con una sensibilidad del 81%, especificidad 86%!


Diagnostic Value of US, MR y MR artrography in shoulder inestability. Roman Pavic et al. Injury Int J. Care (2013) S26-S32!

La RM es la prueba de elección inicial, con una especificidad del 82% y sensibilidad del 94%!!La artro-RM es el gold standard para la evaluación previa a la cirugía.!


La RM es más precisa para lesiones de Hill-Sachs o Bankart!!La artro-RM es superior en lesiones ligamentosas complejas y del labrum!

Diagnostic Value of US, MR y MR artrography in shoulder inestability. Roman Pavic et al. Injury Int J. Care (2013) S26-S32!

Tipo de Inmovilización!

No diferencias entre la inmovilización en rotación externa Vs rotación interna!

Immobilization in internal or external rotation does not change recurrence rates after traumatic anterior shoulder Dislocation. Patrick Vavken, et al. J Shoulder Elbow Surg (2014) 23, 13-19!

final analysis of recurrent dislocation. However, we did findhigh values for post hoc power analysis.

Conclusion

The currently available best evidence does not supporta relative effectiveness of immobilization in externalrotation compared with internal rotation in reducingrecurrent shoulder dislocations in patients with traumaticanterior shoulder dislocations. However, after we

reviewed the current clinical data and the available basicscience, it is our opinion that a yet-to-be-determinedsubgroup of patients could benefit from such treatment.Future investigations are needed to test this hypothesis.

Disclaimer

The authors, their immediate families, and any researchfoundations with which they are affiliated have not

Figure 4 Cumulative RR for recurrent dislocations after immobilization in internal rotation (IR) and external rotation (ER) for patientsaged older than 30 years.

Figure 3 Cumulative RR for recurrent dislocations after immobilization in internal rotation (IR) and external rotation (ER) for patientsaged 30 years or younger. The pooled estimates are very similar to those for all ages, mostly because a large majority of patients withshoulder dislocations are adolescents and young adults.

18 P. Vavken et al.

final analysis of recurrent dislocation. However, we did findhigh values for post hoc power analysis.

Conclusion

The currently available best evidence does not supporta relative effectiveness of immobilization in externalrotation compared with internal rotation in reducingrecurrent shoulder dislocations in patients with traumaticanterior shoulder dislocations. However, after we

reviewed the current clinical data and the available basicscience, it is our opinion that a yet-to-be-determinedsubgroup of patients could benefit from such treatment.Future investigations are needed to test this hypothesis.

Disclaimer

The authors, their immediate families, and any researchfoundations with which they are affiliated have not

Figure 4 Cumulative RR for recurrent dislocations after immobilization in internal rotation (IR) and external rotation (ER) for patientsaged older than 30 years.

Figure 3 Cumulative RR for recurrent dislocations after immobilization in internal rotation (IR) and external rotation (ER) for patientsaged 30 years or younger. The pooled estimates are very similar to those for all ages, mostly because a large majority of patients withshoulder dislocations are adolescents and young adults.

18 P. Vavken et al.

II!Tratamiento conservador!

Tiempo de Inmovilización!

Edad < 13 años es un factor predictivo de recurrencia!!No hay beneficios en inmovilizar > 1 semana en pacientes jóvenes!!

Immobilization in internal or external rotation does not change recurrence rates after traumatic anterior shoulder Dislocation. Patrick Vavken, et al. J Shoulder Elbow Surg (2014) 23, 13-19!

II!

Programa de Rehabilitación!

Consensus statement on shoulder instability. Arthroscopy. 2010 Feb;26(2):249-55. !Bak K, Wiesler ER, Poehling GG; ISAKOS Upper Extremity Committee.!

•  Diseño individualizado!•  Programa de ejercicios!•  Recuperación del rango de

movimiento!•  Ejercicios dinámicos!•  Propioceptivos!•  Estabilización escapular!

III!

Ejercicios Isocinéticos!

Los programas Isocinéticos son eficaces en la evaluación y rehabilitación de la inestabilidad de hombro microtraumatica!

Isokinetic intervention in microtraumatic shoulder instability: an update. Gremeaux V, Croisier JL, Forthomme B. J Sports Med Phys Fitness. 2012 Aug;52(4):413-23. Review. PubMed PMID: 22828467.!

II!

Cirugia!

Chahal J, Marks PH, Macdonald PB, Shah PS, Theodoropoulos J, Ravi B, Whelan DB. Anatomic Bankart repair!compared with nonoperative treatment and/or arthroscopic lavage for first-time traumatic shoulder dislocation.!Arthroscopy 2012; 28(4): 565-575!

II!

La reparación artroscópica reduce la inestabilidad recurrente y mejora la calidad de vida en adultos jóvenes tras la primera luxación.!

Health & Medicine

Evidencias en la rehabilitación del hombro doloroso