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Shoulder Rotator Cuff Disorders: A Systematic Review of Clinical Practice Guidelines and Semantic Analyses of Recommendations
Journal Pre-proof Shoulder rotator cuff disorders: a systematic review of clinical practice guidelines and semantic analyses of recommendations Patrick Doiron-Cadrin, PT, M.Sc., Simon Lafrance, PT, M.Sc, Marie Saulnier, PT, M.Sc., Émie Cournoyer, B.Sc., Jean-Sébastien Roy, PT, Ph.D., Joseph-Omer Dyer, PT, Ph.D., Pierre Frémont, MD, Ph.D., Clermont Dionne, OT, Ph.D., Joy C. MacDermid, PT, Ph.D., Michel Tousignant, PT, Ph.D., Annie Rochette, OT, Ph.D., Véronique Lowry, PT, M.Sc., Nathalie J. Bureau, MD, M.Sc., Martin Lamontagne, MD, Marie-France Coutu psy, Ph.D., Patrick Lavigne, MD, François Desmeules, PT, Ph.D. PII:
S0003-9993(20)30030-7
DOI:
https://doi.org/10.1016/j.apmr.2019.12.017
Reference:
YAPMR 57759
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 10 December 2019 Accepted Date: 12 December 2019
Please cite this article as: Doiron-Cadrin P, Lafrance S, Saulnier M, Cournoyer É, Roy J-S, Dyer J-O, Frémont P, Dionne C, MacDermid JC, Tousignant M, Rochette A, Lowry V, Bureau NJ, Lamontagne M, Coutu psy M-F, Lavigne P, Desmeules F, Shoulder rotator cuff disorders: a systematic review of clinical practice guidelines and semantic analyses of recommendations, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2020), doi: https://doi.org/10.1016/j.apmr.2019.12.017. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc. on behalf of the American Congress of Rehabilitation Medicine
RC DISORDERS GUIDELINES SYSTEMATIC REVIEW
Shoulder rotator cuff disorders: a systematic review of clinical practice guidelines and semantic analyses of recommendations Patrick Doiron-Cadrin PT, M.Sc.1, Simon Lafrance PT, M.Sc.1, Marie Saulnier, PT, M.Sc.1, Émie Cournoyer B.Sc.1, Jean-Sébastien Roy PT, Ph.D.2, 3, Joseph-Omer Dyer PT, Ph.D.4, Pierre Frémont MD, Ph.D.2, Clermont Dionne OT, Ph.D. 2, 5, Joy C. MacDermid PT, Ph.D.6, Michel Tousignant PT, Ph.D.7, Annie Rochette OT, Ph.D.4, 8, Véronique Lowry PT, M.Sc.1, Nathalie J. Bureau MD, M.Sc.9, 10, Martin Lamontagne MD11, Marie-France Coutu psy, Ph.D.13, Patrick Lavigne, MD 1, 14, François Desmeules PT, Ph.D.1, 4
1. Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montreal, Quebec, Canada 2. Department of Rehabilitation, Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada 3. Centre for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Quebec City, Quebec, Canada 4. School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada 5. Centre de recherche du CHU de Québec - Université Laval, Quebec City, Quebec, Canada 6. School of Physical Therapy, Western University, London, Ontario, Canada 7. School of Rehabilitation, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada 8. Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montreal, Quebec, Canada 9. Department of Radiology, Oncology and Nuclear Medicine, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada 10. University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada 11. Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada 12. School of Public Health, University of Montreal, Montreal, Quebec, Canada 13. Centre for Work Disability Prevention and Rehabilitation (CAPRIT), Charles-Le Moyne Hospital Research Centre affiliated with Université de Sherbrooke, Longueuil, Canada 14. Department of Surgery, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
Corresponding author: François Desmeules, PT, Ph. D. University of Montreal Maisonneuve-Rosemont Research Centre 5415, boulevard de l’Assomption Montréal (Québec) H1T 2M4 Canada : [email protected]
FUNDING: This project was financially supported by the Institut de recherche Robert-Sauvé en santé et en sécurité du travail (# 2016-0029). The funding source had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.
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Shoulder rotator cuff disorders: a systematic review of clinical practice guidelines and semantic analyses of recommendations
4 5
ABSTRACT
6 7
Objectives: To perform a systematic review of clinical practice guidelines (CPGs) and semantic analysis of
8
specific clinical recommendations for the management of rotator cuff disorders in adults.
9 10
Data sources: A systematic bibliographic search was conducted up until May 2018 in Medline, Embase
11
and PeDro databases, in addition to twelve clinical guidelines search engines listed on the AGREE Thrust
12
website.
13 14
Study selection: Nine CPGs on the management of rotator cuff disorders in adults and/or workers,
15
available in English or French and published from January 2008 onward, were included and screened by
16
two independent reviewers.
17 18
Data extraction: CPGs methodology was assessed with the AGREE II tool. A semantic analysis was
19
performed to compare the strength of similar recommendations based on their formulation. The
20
recommendations were categorized in a standardized manner considering the following four levels:
21
“Essential”, “Recommended”, “May be recommended” and “Not recommended”.
22 23
Data synthesis: Methodological quality was considered high for three CPGs and low for six. All CPGs
24
recommended active treatment modalities, such as an exercise program in the management of rotator
25
cuff disorders. Acetaminophen and/or NSAIDs prescription and corticosteroid injections were presented
26
as modalities that may be recommended to decrease pain. Recommendations related to medical
27
imagery and surgical opinion varied among the guidelines. The most commonly recommended return to
28
work strategies included intervening early, use of a multidisciplinary approach and adaptation of work
29
organization.
30 31
Conclusions: Only three CPGs were of high quality. The development of more rigorous CPGs is 2019-06-03
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warranted.
33 34
KEYWORDS
35
Rotator Cuff, Evaluation, Treatment, Tendinopathy, Tendon Tear, Return-to-Work, Systematic Review,
36
Qualitative Analysis, Shoulder Impingement Syndrome, Shoulder pain
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LIST OF ABBREVIATION
38
CPGs: Clinical practice guidelines
39
GRADE: Grading of Recommendations Assessment, Development, and Evaluation
40
MRI: Magnetic resonance imaging
41
NSAID: Nonsteroidal anti-inflammatory drug
42
NHMRC: National Health and Medical Research Council
43
RC: Rotator cuff
44
RTW: Return to work
45
SIGN: Scottish Intercollegiate Guidelines Network
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Rotator cuff (RC) disorders are the most frequent group of pathologies affecting the shoulder
47
and represent 50% to 85% of shoulder conditions treated by health professionals (1). This group of
48
pathology includes tendinopathies, partial tears and full-thickness tears of one or more tendons of the
49
rotator cuff (2).
50
The point prevalence of shoulder pain varies from 6.9 to 26% in the general population and
51
increases with aging (3). The prevalence of RC abnormalities in the general population increase with
52
aging, reaching an estimate of 31% in adults between 60 and 69 years old and 65% in adults overs 80
53
years old (4). Without appropriate care, individuals with rotator cuff disorders are subject to persistent
54
pain over time (5). This situation highlights the importance of establishing a rapid and valid diagnosis,
55
while offering the best available evidence-based care to individuals of working age presenting with such
56
conditions.
57
Clinical practice guidelines (CPGs) have been developed for the treatment of rotator cuff
58
disorders in adults (6-14). CPGs are generally referred as “systematically developed statements to assist
59
practitioner decisions about appropriate health care for specific clinical circumstances” (15). While CPGs
60
offer a convenient way to transfer scientific knowledge into clinical practice for healthcare practitioners,
61
adherence to their content and recommendations remains suboptimal (16, 17).
62
Barriers to the uptake of clinical recommendations include, the use of weak or conflicting
63
evidence, the lack of applicability and ambiguous formulation have already been identified (18). In
64
addition, the methodological quality of clinical guidelines has been shown to vary widely from an
65
organization to another (19, 20) and conflicting recommendations on a same topic can be a source of
66
confusion for health-care providers, patients and stakeholders (21-23). Nonetheless, multiple systems to
67
grade evidence are currently used by authoring organizations to classify the strength and/or the level-of-
68
evidence underlying clinical recommendations, while other institutions simply do not present grading
69
scales at all (24). Comparing clinical recommendations from different publications can thus represent a
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challenge. Qualitative thematic analysis of recommendations, based on the choice of semantic fields for
71
the formulation of recommendations rather than on a specific scale, can be helpful to overcome this
72
obstacle (25).
73
The aim is therefore to systematically review and critically appraise recent CPGs developed for
74
the management of rotator cuff disorders in adult, including evaluation, conservative and surgical
75
treatments as well as return to work strategies and to synthesize, through a semantic analysis current
76
evidence regarding the most consensual recommendations for rotator cuff disorders in adults.
77 78
METHODS
79
Identification, Selection of Guidelines and Quality Appraisal
80
A systematic bibliographic search was conducted up until May 2018, in Medline, Embase and
81
PeDro databases, in addition to twelve clinical guidelines search engines listed on the AGREE Thrust
82
website (see Figure 1). The keywords “shoulder”, “tendinopathy”, “rotator cuff”, “shoulder girdle”,
83
“upper limb” and “guidelines” were used to identify clinical guidelines (exact search is presented in
84
supplementary material). A manual search was also conducted through the identified guidelines
85
reference lists. Inclusion criteria for the clinical guidelines were: 1-containing recommendations on the
86
evaluation, treatment and/or return-to-work of adults or workers presenting a rotator cuff disorder; 2-
87
published recently (from January 2008 onward); 3- available in English or French. Clinical guidelines with
88
an exclusive scope on other shoulder pathologies such as adhesive capsulitis, shoulder fractures, labral
89
tears, arthritis or other shoulder disorders were excluded.
90
References were retrieved from databases and duplicates were removed. Two reviewers (PDC
91
and MS) screened titles and abstracts from the reference list in order to assess eligibility for inclusion.
92
Full texts were retrieved and assessed (PDC and MS). Reference lists from full-text documents were
93
checked for relevant citations. In case of disagreement, a consensus was reached between the pair of 2019-06-03
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reviewers at all stages process. When two or more guidelines from the same organization and the same
95
committee were identified, only the most recent was included.
96
Clinical guidelines characteristics were extracted by two reviewers (PDC and SL), using a
97
standardized form documenting titles, organizations, year of publication, reported objectives and
98
presence of recommendations specifically targeted to injured workers. Methodological elements such as
99
the professional groups involved, the presence of a systematic review of the literature, the declaration of
100
competing interests, the description of the methods to formulate the recommendations, the presence of
101
an explicit link between the scientific evidence and the recommendations, and the presence of an
102
external revision process were also compiled.
103
Clinical guidelines methodological quality was assessed by pairs of reviewers (PDC, EC, MS, SL)
104
based on the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. The AGREE II
105
appraisal tool comprises 23 key items rated on a 7-point scale (1—Strongly disagree to 7—Strongly
106
agree). The items are summarized in six domains (Scope and Purpose, Stakeholder involvement, Rigour
107
of Development, Clarity of Presentation, Applicability, and Editorial Independence). This validated tool
108
has been widely used to evaluate the methodology quality of clinical guidelines worldwide (26). The final
109
score for each clinical guideline was obtained by means between pairs of reviewers as recommended by
110
the AGREE instrument methodology (27).
111 112 113
Semantic Analysis and Synthesis of Recommendations Clinical recommendations were extracted from the clinical guidelines, coded and pooled by a
114
reviewer (PDC) into nine categories: clinical evaluation, medical imaging, medication for RC
115
tendinopathy, medication for RC full-thickness tears, rehabilitation modalities for RC tendinopathy,
116
rehabilitation modalities for RC full-thickness tears, surgical interventions for RC tendinopathy, surgical
117
interventions for RC full-thickness tears and return-to-work strategies for all RC disorders. The categories
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were then refined and confirmed by a second reviewer (SL).
119
A semantic analysis was performed to compare the strength of similar recommendations based
120
on their formulation (28, 29). The recommendations were categorized according to their strength in a
121
standardized manner considering the following four levels: “Essential”, “Recommended”, “May be
122
recommended” and “Not recommended” (see Table 1). The analysis was based on the semantic fields for
123
the terms “obligation”, “recommendation” and “possibility” for the recommended activities, modalities
124
or strategies (30, 31). All the non-recommended activities, modalities or strategies were categorized as
125
“not recommended” (Table 1).
126
All recommendations presented in the included CPGs, as well as the accompanying explanations,
127
were subject to the semantic analysis and a second reviewer (SL) validated data results. A consensus was
128
needed between reviewers; a third reviewer was available to discuss any disagreement.
129 130
RESULTS
131
Included Guidelines Characteristics
132
Ten clinical guidelines were identified during the systematic review (6, 7, 9, 11, 14, 32-36). One
133
guideline was later excluded because the complete version was only available in Danish (36). Data were
134
extracted from the remaining nine guidelines (Figure 1). All the guidelines were published between 2008
135
and 2015 in English, seven guidelines covered clinical evaluation activities or strategies (7, 9, 11, 14, 32-
136
34), eight guidelines covered medical imaging prescriptions (7, 9, 11, 14, 32-35), seven guidelines
137
covered medication prescriptions, rehabilitation modalities and surgery or surgical techniques (6, 7, 9,
138
11, 14, 32, 35), and six guidelines contained recommendations on return to work strategies (7, 9, 11, 14,
139
32, 35).
140 141
The CPGs characteristics and AGREE II composite domain scores are presented in table 2. Three CPGs were considered of high methodological quality (6, 9, 33) while six were considered of lower 2019-06-03
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methodological quality (7, 11, 14, 32, 34, 35). A systematic review of the relevant literature was involved
143
in the development of seven guidelines (6, 7, 9, 14, 32, 33, 35). An explicit link between the scientific
144
evidence and the recommendations was present in four guidelines (6, 7, 9, 33). Three guidelines included
145
a declaration of conflicting interests, involved a systematic consultation of stakeholders and explicitly
146
stated that an external revision process was performed (6, 9, 33).
147 148 149
Assessment of Shoulder Pain Thirteen clinical evaluation activities or strategies were identified in seven guidelines (9, 11, 14,
150
32-35). Taking a medical history, performing a physical examination, identifying red and yellow flags,
151
measuring shoulder range of motion and strength and using validated questionnaires to assess patient’s
152
condition were considered essential elements or were recommended in all guidelines. Using shoulder
153
specific clinical tests and contacting an interpreter if needed were either “recommended” or “may be
154
recommended”, while performing a functional capacity evaluation and use of local anesthetic injections
155
in the subacromial space for diagnostic purpose were considered as “may be recommended”, when the
156
subject was covered.
157 158
Medical Imaging for Rotator Cuff Disorders
159
Prescribing radiography for the initial assessment or during the follow-up of patients, diagnostic
160
ultrasound, magnetic resonance (MRI) and magnetic resonance arthrography (MRA) were considered as
161
“may be recommended”, when the subject was covered. Radiography was indicated at initial
162
consultation in the presence of a history of trauma (14, 32, 33) or if a diagnosis other than a RC disorder
163
was suspected after the clinical evaluation (9, 11, 14). At the follow-up, conventional radiography was
164
“recommended” in the absence of improvement after an adequate conservative treatment when
165
reviewed (7, 9, 11, 32, 33, 35). Diagnostic ultrasound was “recommended” in the absence of 2019-06-03
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improvement after conservative care (7, 11, 32, 33, 35), if there is a “lack of access to MRI” (9) or to
167
“rule-out a RC tear” in one guideline (32). MRI was “recommended” in the absence of improvement after
168
conservative care (9, 11, 32, 33), prolonged refractory or unexplained pain (34), significant weakness on
169
shoulder elevation or rotation (35), suspected RC tear (14) or if diagnostic ultrasound was inconclusive
170
(7). MRA was recommended to investigate a possible intra-articular lesion or an associated
171
glenohumeral instability (7, 11, 34, 35), for suspected partial RC tear (7, 34) or if the diagnosis was not
172
identified with standard imagery techniques (35).
173 174
Medication for Rotator Cuff Tendinopathy
175
Thirteen activities related to medication prescriptions for RC tendinopathy were identified
176
among a total of seven guidelines (6, 7, 9, 11, 14, 32, 35). Four guidelines did cover the prescription of
177
acetaminophen, which was “recommended” for mild or moderate pain in two guidelines (9, 11) and
178
“may be recommended” without specific indications in two others (14, 35). Seven guidelines covered
179
and considered the prescription of NSAIDS as “may be recommended” for the treatment of shoulder
180
pain without specific indications (6, 7, 9, 11, 14, 32, 35).
181
Corticosteroids injections were considered as “may be recommended” in all guidelines, when
182
reviewed, but indications varied substantially: in the presence of persistent pain after a conservative
183
treatment (7, 9), if there is a “positive response” to a diagnostic analgesic injection (11), in the absence
184
of response to “manual methods” (32) or was considered as “may be recommended” without any
185
specific indications in two guidelines (14, 35). Patient education regarding the prescribed medication was
186
recommended in three guidelines, but the content of the information to provide was not specified (7, 11,
187
35).
188 189
Medication for Rotator Cuff Full-Thickness Tear 2019-06-03
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Eleven activities related to medication prescriptions for RC full-thickness tears were identified
191
among a total of six guidelines (6, 9, 11, 14, 32, 35). Acetaminophen prescription was “recommended” in
192
two guidelines (9, 11) and as “may be recommended” without further details in two others (14, 35).
193
Indications for various medications varied substantially from a publication to another. Tramadol
194
was as “may be recommended” for “patients without prior opioid addiction” in one guideline (35) and if
195
there is “no response to manual methods” in another one (11). Opioids were as “may be recommended”
196
if regular assessments are possible, in one guideline (9), and in the presence of severe upper extremity
197
pain, in another one (35). Hypnotics were considered as “may be recommended” in case of sleep
198
disorders in two guidelines (11, 35)}. Muscle relaxant and anti-anxiety medications were covered in two
199
guidelines and subject to conflicting recommendations (not recommended vs. may be recommended)
200
(11, 35). Patient education regarding the prescribed medication was “recommended” in two guidelines,
201
but the content of the information to be provided was not specified (11, 35).
202 203
Corticosteroids injections were considered as “may be indicated” in a case of persistent pain after an adequate conservative treatment (9) and in the “absence of response to manual methods” (32).
204 205
Rehabilitation Modalities for Rotator Cuff Tendinopathy
206
Sixteen rehabilitation modalities or treatment approaches were identified among a total of
207
seven guidelines and exercise prescription was recommended in all of them (6, 7, 9, 11, 14, 32, 35).
208
Manual therapy modalities and psychosocial interventions were “recommended” or “may be
209
recommended” in a total of six guidelines (7, 9, 11, 14, 32, 35). Heat or cold applications, acupuncture,
210
TENS and using a multidisciplinary approach were reviewed in a total of six guidelines and defined as
211
“may be recommended” in all of them (6, 7, 9, 11, 32, 35). Taping, microwave diathermy and laser were
212
“not recommended” and reviewed in two guidelines (11, 35).
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Rehabilitation Modalities for Full-Thickness Rotator Cuff Tear Fourteen rehabilitation modalities or treatment approaches were identified among a total of five
216
guidelines. Exercise prescription was “recommended” in three guidelines (9, 11, 14) and as “may be
217
recommended” in another one (35). Manual therapy modalities were “recommended” in one guideline
218
(14) and were as “may be recommended” in three others (9, 11, 35). Heat or cold applications,
219
acupuncture, therapeutic ultrasound, TENS, psychosocial interventions and using a multidisciplinary
220
approach were classified as “may be recommended” in three guidelines (9, 11, 35).
221 222
Interventions Related to Surgery or Other Medical Interventions for Rotator Cuff
223
Tendinopathy
224
Seven interventions related to surgery and surgical approaches were identified among a total of
225
six guidelines (7, 9, 11, 14, 32, 35). Referring for a surgical opinion was “recommended” in five
226
guidelines in varied circumstances: in the presence of a “significant activity limitation, participation
227
restriction and/or persistent pain after a nonsurgical treatment of three months” (9), in the “absence of
228
improvement after a three to six-month rehabilitation program” (35), if “pain is worsening after three to
229
six weeks or in the presence of inadequate improvement at 7-8 weeks” (32), if “no improvement with 6
230
weeks of conservative intervention and rehabilitation program” (11) and if “no improvement with
231
conservative intervention and rehabilitation program” (14). Acromioplasty was considered as an
232
intervention that may be indicated after an active rehabilitation program in three guidelines (11, 14, 35).
233
Recommendations for percutaneous lavage were present in four guidelines and were “may be indicated”
234
in the absence of improvement after conservative care in three guidelines (9, 14, 35), and without
235
additional details in another one (7). Both open and arthroscopic surgery approaches for the treatment
236
of RC tendinopathy were “recommended” in all four guidelines covering the subject (7, 9, 32, 35).
237
Platelet-rich plasma injections in the treatment of RC tendinopathy were considered as “may be 2019-06-03
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recommended” in one guideline (35) and were “not recommended” as a treatment in another one (32).
239 240
Interventions Related to Surgery for Rotator Cuff Full-Thickness Tear
241
Ten interventions related to surgery and surgical approaches were identified among a total of six
242
guidelines (7, 9, 11, 14, 32, 35). Referring for a surgical opinion was “recommended” in all six guidelines,
243
but in various circumstances: “in the presence of a full-thickness tear” (6, 9, 11), in the presence of an
244
“acute full-thickness RC tear of >1 cm or no response to a conservative treatment for tears <1 cm” (35), if
245
a RC tear is suspected with no response to four to six weeks of “manual methods” (32) and in the
246
presence of a symptomatic full-thickness RC tear or after a conservative treatment in the presence of a
247
chronic tear and for patients of 65 years and older (14). Performing an acromioplasty in conjunction with
248
a RC repair was “not recommended” in all three guidelines covering the subject (6, 14, 35). Performing a
249
RC repair by single vs. double rows, or by open surgery vs. arthroscopy were equally recommended in
250
three guidelines (9, 14, 35). Performing a graft was also “not recommended” based on recommendations
251
in two guidelines (14, 35).
252 253 254
Return-to-Work Strategies for Rotator Cuff Disorders Eleven interventions or strategies related to return to work (RTW) were identified among a total
255
of six guidelines (7, 9, 11, 14, 32, 35). The most commonly recommended return to work strategies
256
included intervening early, use of a multidisciplinary approach and adaptation of work organization.
257
Intervening early, establishing a RTW plan using shared decision-making process, maintaining
258
communication between the worker and the employer, establishing realistic goals for RTW were
259
“recommended” or considered “essential” in all guidelines that covered the subject (9, 11, 14, 35). All
260
other interventions or strategies were either “recommended”, or “may be recommended”, when
261
covered and details of these interventions are presented in the Supplementary Material (7, 9, 11, 14, 32, 2019-06-03
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35).
263 264
DISCUSSION
265
The aim of this systematic review was to systematically review and critically appraise recent CPGs
266
developed for the management of rotator cuff disorders in adults, including evaluation, conservative and
267
surgical treatments. To our knowledge, this review is the first to use a semantic analysis approach to
268
synthesize the published recommendations for this population.
269
Among the guidelines identified through our systematic search, publications from three
270
organizations stood out for their methodological quality: the University of New South Wales (9), the
271
American Academy of Orthopaedic Surgeons (6) and the National University of Health Sciences (33)
272
guidelines. The development process for those clinical guidelines included systematic reviews and
273
consultation of the stakeholders, presented a statement on conflicts of interests and explicit methods for
274
formulating the recommendations, in addition to an external review. Those three guidelines also
275
systematically tended to score higher for all the other AGREE II domains. Some of the AGREE domains,
276
like “Applicability”, “Development” and “Independence”, systematically presented very low scores
277
among the other guides.
278
Concerns about the overall methodological quality of clinical guidelines have been raised before
279
(37). This review tends to demonstrate that improvements in clinical guideline development and
280
publication process are still to be expected nowadays for the guidelines covering the evaluation, the
281
treatment and the return-to-work of adults presenting a RC disorder.
282
The qualitative analysis presented in this systematic review underlines that many of the currently
283
published recommendations covering evaluation, treatment or return-to-work strategies with adults
284
presenting a RC disorder are often inconsistent. Some interventions were, however, recommended on a
285
more consensual basis, such as all clinical evaluation activities, which were either considered “Essential”, 2019-06-03
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“Recommended” or “May be recommended”, although the exact content of a valid physical examination
287
was not precisely defined. Prescribing exercise for the treatment of RC tendinopathy and RC full-
288
thickness tear was universally recommended among the guidelines covering this subject. Manual therapy
289
was either considered “recommended” or “may be recommended”, theses recommendations are in line
290
with the results of a systematic review published by Desjardins-Charbonneau et al., (38) which concluded
291
that manual therapy may decrease pain in adults with RC tendinopathy. In the same order of ideas, a
292
Cochrane review reported that the effect of manual therapy and exercise may be similar to those of
293
corticosteroid injections and subacromial decompression surgery, but may not lead to clinically
294
important effect when compared to a placebo (39). In all guidelines, prescribing acetaminophen, NSAIDS
295
and corticosteroid injections were presented as “may be recommended” options for the treatment RC
296
tendinopathy and RC full-thickness tear. The effect of platelet-rich plasma injections in the treatment of
297
RC tendinopathy remained unclear. A meta-analysis reported that platelet-rich plasma injections
298
significantly reduce pain and disability when compared to a placebo injection or to dry needling (40).
299
However, this review only included two RCTs on RC tendinopathy and could not conclude if the effect
300
was clinically important or not.
301
Regarding surgical interventions, performing an acromioplasty for the treatment of RC
302
tendinopathy was presented as a treatment option after the failure of conservative treatments,
303
however, it is important to highlight that these CPGs were published before two RCTs that report no
304
benefit of arthroscopic subacromial decompression compared to a placebo surgery and no clinically
305
important difference when compared to no intervention or exercise therapy (41, 42). Routine
306
acromioplasty during a RC repair was universally not recommended. Single row sutures, double row
307
sutures, open approach and arthroscopy were presented as equally effective in all guidelines for the
308
reparation of RC full-thickness tears. All the identified return-to work strategies were either
309
“Recommended” or “May be recommended” in all guidelines that covered the subject.
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310
On the other hand, other recommendations were subject to high heterogeneity across the
311
retrieved guidelines. For instance, indications for medical imaging tests like radiography, diagnostic
312
ultrasound, MRI and MRA varied among CPGs. This could be explained by comparable diagnostic
313
capabilities among diagnostic ultrasound, MRI and MRA for RC tear, with slightly higher sensitivity and
314
sensibility for MRA (43). Indications to refer for a surgical opinion also varied among the CPGs, which
315
could be explained by a lack of evidence regarding surgical indications for RC disorders (44-46).
316
Therapeutic ultrasounds were “may be recommended” for the treatment of RC tendinopathy in some
317
guidelines, and “not recommended” in others. Those conflicting recommendations can render the
318
clinical decision-making process rather difficult for the healthcare professionals.
319
Another issue is the use of multiple scales to appraise the quality of the evidence and the
320
strength of recommendations such as National Health and Medical Research Council (NHMRC),
321
Scottish Intercollegiate Guidelines Network (SIGN), or Grading of Recommendations Assessment,
322
Development, and Evaluation (GRADE) scales. This situation clearly represents a challenge even if several
323
guidelines gave adequate information on the utilization of the appraisal scales. Still, four of the retrieved
324
guidelines in this review do not explicitly state a standardized appraisal scale (11, 14, 32, 34). This
325
impediment has been encountered by authors of other clinical guidelines systematic reviews and
326
creative approaches, such as creating a new scale or converting the recommendations to a unified level
327
of evidence grading scale, have been employed (19, 22). The qualitative thematic analysis presented in
328
this systematic review allowed a comparison between the complete set of currently published
329
recommendations, which would not have been possible otherwise. Similar approaches to ours, based on
330
an analysis of the formulation rather than a strength-of-recommendation or level-of-evidence scale, has
331
been used in previous clinical guidelines systematic reviews (47, 48).
332 333
Those findings thus underline an urge for standardizing and simplifying the formulation of clinical recommendations among authoring organizations. While clinical guidelines aim to “assist practitioner
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RC DISORDERS GUIDELINES SYSTEMATIC REVIEW
334
and patient decisions about appropriate healthcare for specific clinical circumstances” (15), an explicit
335
link between scientific evidence and recommendations remains essential to allow clinicians, stakeholders
336
and consumers to evolve in an evidence-based practice framework (49). Furthermore, ambiguous
337
recommendation formulations, such as “It is recommended that by using patient feedback and response
338
as a guide, increasing grades of amplitude may be applied” (32), were present in several guidelines and
339
could be confusing for the reader. It has been demonstrated that recommendations formulated in a
340
simple manner are associated with a better uptake by clinicians (50). Clinical recommendations should
341
thus be formulated in that sense.
342
Furthermore, most of the identified guidelines were based on a biomedical model. Several
343
studies and systematic reviews have recognized the effectiveness and cost-effectiveness of
344
interdisciplinary interventions that included support during return to work (51-55). Work disability field
345
literature also highlights the importance of communication between patients and healthcare
346
professionals, as it can influence the recovery trajectory for injured workers (56). Surprisingly, such
347
interventions were scarcely covered and discussed in the retrieved guidelines.
348
This review presents many strengths, among which an extensive systematic search in three
349
major scientific databases, in addition to twelve other guideline databases and medical societies’
350
websites. The validated AGREE II appraisal instrument was also used to compare the methodological
351
quality between the guidelines. Since no cut-off score has been identified for the AGREE II instrument,
352
methodological items were extracted from the different domains to allow an objective comparison of
353
the identified guidelines.
354
Our review also presents some limits. Since only guidelines published in English or French were
355
retained, other relevant publications could have been missed. The excluded guideline by the Danish
356
Authority is an example of this limitation (36). The fact that only two reviewers appraised the
357
methodological quality of the guidelines could also potentially impact the results, since concerns about
2019-06-03
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RC DISORDERS GUIDELINES SYSTEMATIC REVIEW
358
inter-reviewer fidelity have been raised for the AGREE instrument (24). Likewise, no verification upon the
359
quality or the sources for the scientific evidence underlying the clinical recommendations was sought.
360
Variations in the evidence could explain some discrepancies between the recommendations presented in
361
the included guidelines, but those analyses would not have been possible for all of them due to a lack of
362
methodological information and transparency.
363 364 365
CONCLUSIONS In this systematic review, a qualitative thematic analysis was used to compare recommendations
366
from nine clinical guidelines on the evaluation, treatment and the return-to-work of adults presenting a
367
shoulder RC disorder. Three clinical guidelines were considered of high methodological quality, while six
368
were considered of lower methodological quality. Prescribing exercise for the treatment of RC
369
tendinopathy was universally recommended. All identified clinical evaluation activities and all return-to-
370
work strategies were presented as modalities that may be recommended for that population. Indication
371
for medical imagery (radiography, diagnostic ultrasounds and MRI) and surgical opinion varied among
372
the guidelines. Since this can be confusing for healthcare professionals there is a need to standardize the
373
way clinical recommendations are formulated. The same applies to the reporting for strength and level
374
of evidence among guidelines. Enhancing the clinical guideline development process regarding the
375
applicability, the development and the declaration of competing interests are mandatory in order to
376
allow the health-care professionals to fully appraise and uptake their content.
377 378 379
AUTHORS’ CONTRIBUTIONS:
380
PDC designed the study protocol, performed the literature search, selected the articles of interest,
2019-06-03
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RC DISORDERS GUIDELINES SYSTEMATIC REVIEW
381
performed the risk-of-bias analysis, extracted the data, led the interpretation of results, and wrote the
382
manuscript. SL participated in the selection of the articles, risk-of-bias analysis, data extraction, results
383
interpretation and writing the manuscript. MS and EC participated in risk-of-bias analysis, data extraction
384
and writing of the manuscript. JSR, JOD, PF, CD, MT, AR, VL, NJB, ML, MFC participated in the protocol
385
design, interpretation of results and reviewed the article. JCM participated in the protocol design and
386
reviewed the article. PL participated in the interpretation of results and reviewed the article. FD
387
participated in the design, interpretation of results, writing of the manuscript, managed the project and
388
is the corresponding author.
389 390 391 392
COMPETING INTERESTS The authors declare that they have no competing interests.
393 394 395
WORD COUNT: 4181 words
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396
TABLES AND FIGURES
397 398 399 400 401 402 403 404 405 406
Figure 1: Flow diagram for the systematic review selection progress Table 1: Thematic classification for the clinical recommendations in the included guidelines Table 2: Clinical guidelines characteristics Supplementary material 1: Clinical guidelines recommendations summary Supplementary material 2: Complete AGREE II scores for the retrieved guidelines Supplementary material 3: Systematic review search strategies for scientific databases
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REFERENCES 1. Tekavec E, Jöud A, Rittner R, Mikoczy Z, Nordander C, Petersson IF, et al. Populationbased consultation patterns in patients with shoulder pain diagnoses. BMC musculoskeletal disorders. 2012;13(1):238. 2. Nho SJ, Yadav H, Shindle MK, MacGillivray JD. Rotator cuff degeneration: etiology and pathogenesis. The American journal of sports medicine. 2008;36(5):987-93. 3. Luime J, Koes B, Hendriksen I, Burdorf A, Verhagen A, Miedema H, et al. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scandinavian journal of rheumatology. 2004;33(2):73-81. 4. Teunis T, Lubberts B, Reilly BT, Ring D. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. Journal of Shoulder and Elbow Surgery. 2014;23(12):1913-21. 5. Heijbel B, Josephson M, Jensen I, Vingård E. Employer, insurance, and health system response to long-term sick leave in the public sector: policy implications. Journal of Occupational Rehabilitation. 2005;15(2):167-76. 6. American Academy of Orthopaedic Surgeons. Optimizing the management of rotator cuff problems guideline and evidence report. 2010. 7. Diercks R, Bron C, Dorrestijn O, Meskers C, Naber R, de Ruiter T, et al. Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association. Acta orthopaedica. 2014;85(3):314-22. 8. Haute Autorité de Santé. Pathologies non opérées de la coiffe des rotateurs et massokinésithérapie. Paris: Haute Autorité de Santé. 2001. 9. Hopman K, Krahe L, Lukersmith S, McColl AR, Vine K. Clinical Practice Guidelines for the Management of Rotator Cuff Syndrome in the Workplace. . The University of New South Wales; 2013. 10. Institution of Occupational Safety and Health. A healthy return – good practice guide to rehabilitating people at work. 2015. 11. New York State Workers' Compensation Board. New York Shoulder Injury Medical Treatment Guidelines. 2013. 12. New Zealand Guidelines Group (NZGG). Guideline for diagnosis and treatment of subacromial pain syndrome. 2004. 13. Stock S, Baril R, Dion-Hubert C, Lapointe C, Paquette S, Sauvage J, et al. Troubles musculo-squelettiques - Guide et outils pour le maintien et le retour au travail IRSST; 2005. 14. Washington State Department of Labor and Industries. Medical Treatment Guidelines. 2013. 15. Lohr KN, Field MJ. Clinical practice guidelines: directions for a new program: National Academies Press; 1990. 16. Carlson VR, Ong AC, Orozco FR, Hernandez VH, Lutz RW, Post ZD. Compliance with the AAOS guidelines for treatment of osteoarthritis of the knee: a survey of the American association of hip and knee surgeons. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2018;26(3):103-7. 17. Etchepare F, Pambrun E, Bégaud B, Verdoux H, Tournier M. Compliance of psychotropic 2019-06-03
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drug prescription with clinical practice guidelines in older inpatients. Fundamental & clinical pharmacology. 2016;30(1):82-92. 18. Kastner M, Bhattacharyya O, Hayden L, Makarski J, Estey E, Durocher L, et al. Guideline uptake is influenced by six implementability domains for creating and communicating guidelines: a realist review. Journal of clinical epidemiology. 2015;68(5):498-509. 19. Larmer PJ, Reay ND, Aubert ER, Kersten P. Systematic review of guidelines for the physical management of osteoarthritis. Archives of physical medicine and rehabilitation. 2014;95(2):375-89. 20. Lin I, Wiles LK, Waller R, Goucke R, Nagree Y, Gibberd M, et al. Poor overall quality of clinical practice guidelines for musculoskeletal pain: a systematic review. Br J Sports Med. 2018;52(5):337-43. 21. Ferket BS, Grootenboer N, Colkesen EB, Visser JJ, van Sambeek MR, Spronk S, et al. Systematic review of guidelines on abdominal aortic aneurysm screening. Journal of vascular surgery. 2012;55(5):1296-304. e4. 22. Jolliffe L, Lannin NA, Cadilhac DA, Hoffmann T. Systematic review of clinical practice guidelines to identify recommendations for rehabilitation after stroke and other acquired brain injuries. BMJ open. 2018;8(2):e018791. 23. Paraskevas KI, Mikhailidis DP, Veith FJ. Comparison of the five 2011 guidelines for the treatment of carotid stenosis. Journal of vascular surgery. 2012;55(5):1504-8. 24. MacDermid JC, Brooks D, Solway S, Switzer-McIntyre S, Brosseau L, Graham ID. Reliability and validity of the AGREE instrument used by physical therapists in assessment of clinical practice guidelines. BMC Health Services Research. 2005;5(1):18. 25. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC medical research methodology. 2008;8(1):45. 26. Vlayen J, Aertgeerts B, Hannes K, Sermeus W, Ramaekers D. A systematic review of appraisal tools for clinical practice guidelines: multiple similarities and one common deficit. International Journal for Quality in Health Care. 2005;17(3):235-42. 27. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. Cmaj. 2010;182(18):E839-E42. 28. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006;3(2):77-101. 29. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qualitative health research. 2005;15(9):1277-88. 30. Hinkel E. The use of modal verbs as a reflection of cultural values. TESOL quarterly. 1995;29(2):325-43. 31. Rosenberg Lv. Do I have to? On the Expression of Degrees of Obligation in the Official English Version and the Dutch Translation of CEDAW 2013. 32. Industrial Insurance Chiropractice Advisory Committe. Conservative Care Options for Work-Related Mechanical Shoulder Conditions. Washington State Department of Labor and Industries; 2014. 33. Bussières AE, Peterson C, Taylor JA. Diagnostic imaging guideline for musculoskeletal complaints in adults—an evidence-based approach—part 2: upper extremity disorders. Journal of Manipulative & Physiological Therapeutics. 2008;31(1):2-32. 2019-06-03
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34. American College of Radiology. ACR–SPR–SSR practice parameter for the performance interpretation of magnetic resonance imaging of the shoulder. 2015. 35. Colorado Department of Labor and employment. Shoulder Injury Medical Treatment Guidelines. Colorado Department of Labor and employment; 2015. 36. Danish Health Authority. National clinical guideline on diagnostics and treatment of patients with selected shoulder conditions quick guide. 2016. 37. Shaneyfelt TM, Mayo-Smith MF, Rothwangl J. Are guidelines following guidelines?: The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. Jama. 1999;281(20):1900-5. 38. Desjardins-Charbonneau A, Roy J-S, Dionne CE, Frémont P, MacDermid JC, Desmeules F. The efficacy of manual therapy for rotator cuff tendinopathy: a systematic review and metaanalysis. journal of orthopaedic & sports physical therapy. 2015;45(5):330-50. 39. Page MJ, Green S, McBain B, Surace SJ, Deitch J, Lyttle N, et al. Manual therapy and exercise for rotator cuff disease. Cochrane Database of Systematic Reviews. 2016(6). 40. Tsikopoulos K, Tsikopoulos I, Simeonidis E, Papathanasiou E, Haidich A-B, Anastasopoulos N, et al. The clinical impact of platelet-rich plasma on tendinopathy compared to placebo or dry needling injections: A meta-analysis. Physical Therapy in Sport. 2016;17:87-94. 41. Beard DJ, Rees JL, Cook JA, Rombach I, Cooper C, Merritt N, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet. 2018;391(10118):329-38. 42. Paavola M, Malmivaara A, Taimela S, Kanto K, Inkinen J, Kalske J, et al. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial. bmj. 2018;362:k2860. 43. De Jesus JO, Parker L, Frangos AJ, Nazarian LN. Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis. American Journal of Roentgenology. 2009;192(6):1701-7. 44. Keener JD, Patterson BM, Orvets N, Chamberlain AM. Degenerative rotator cuff tears: refining surgical indications based on natural history data. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2019;27(5):156-65. 45. Oh LS, Wolf BR, Hall MP, Levy BA, Marx RG. Indications for rotator cuff repair: a systematic review. Clinical Orthopaedics and Related Research®. 2007;455:52-63. 46. Thorpe A, Hurworth M, O'Sullivan P, Mitchell T, Smith A. Rotator cuff disease: opinion regarding surgical criteria and likely outcome. ANZ journal of surgery. 2017;87(4):291-5. 47. Abbott AL, Paraskevas KI, Kakkos SK, Golledge J, Eckstein H-H, Diaz-Sandoval LJ, et al. Systematic review of guidelines for the management of asymptomatic and symptomatic carotid stenosis. Stroke. 2015;46(11):3288-301. 48. Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM, editors. A systematic review of recommendations and guidelines for the management of osteoarthritis: the chronic osteoarthritis management initiative of the US bone and joint initiative. Seminars in arthritis and rheumatism; 2014: Elsevier. 49. Rycroft‐Malone J, Seers K, Titchen A, Harvey G, Kitson A, McCormack B. What counts as evidence in evidence‐based practice? Journal of advanced nursing. 2004;47(1):81-90. 50. Michie S, Lester K. Words matter: increasing the implementation of clinical guidelines. 2019-06-03
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BMJ Quality & Safety. 2005;14(5):367-70. 51. Franche R-L, Cullen K, Clarke J, Irvin E, Sinclair S, Frank J, et al. Workplace-based returnto-work interventions: a systematic review of the quantitative literature. Journal of occupational rehabilitation. 2005;15(4):607-31. 52. Hlobil H, Staal JB, Spoelstra M, Ariëns GA, Smid T, van Mechelen W. Effectiveness of a return-to-work intervention for subacute low-back pain. Scandinavian journal of work, environment & health. 2005:249-57. 53. Loisel P, Lemaire J, Poitras S, Durand M-J, Champagne F, Stock S, et al. Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six year follow up study. Occupational and Environmental Medicine. 2002;59(12):807-15. 54. Schonstein E, Kenny DT. The value of functional and work place assessments in achieving a timely return to work for workers with back pain. Work. 2001;16(1):31-8. 55. Yassi A, Tate R, Cooper J, Snow C, Vallentyne S, Khokhar J. Early intervention for backinjured nurses at a large Canadian tertiary care hospital: an evaluation of the effectiveness and cost benefits of a two-year pilot project. Occupational Medicine. 1995;45(4):209-14. 56. Coutu M-F, Légaré F, Durand M-J, Corbière M, Stacey D, Bainbridge L, et al. Operationalizing a shared decision making model for work rehabilitation programs: a consensus process. Journal of occupational rehabilitation. 2015;25(1):141-52.
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Identification
Records identified through scientific databases Medline (n=288) Embase (n=358) Pedro (n=24)
Sceening
Records after duplicates removed n=495
Records after title and abstract screening n=2
Records identified through medical societies and guidelines databases proposed by the AGREE thrust National Guideline Clearinghouse (n=90) National Institute for Health and Care Excellence (n=250) Canadian Medical Association (n=3) Scottish Intercollegiate Guideline Network (n=57) National Health and Medical Research Council (n=2) eGuidelines (MGD Ltd.) (n=1) Guidelines-International-Network (n=312) TRIP database (n=362) Royal Dutch Society for Physical Therapy (n=15) Ministry of Health – New Zealand (n=0) American Academy of Orthopaedic Surgeons (n=27) GuidelineCentral (n= 67 566 results, research stopped after 4 pages of results)
Records retained after title and abstract screening n=11
Records after duplicate records removed n=10
Included
Elligibility
Full-text publications assessed for eligibility n=10
Records identified through manual searching n=0
Excluded Complete guide unavailable in English (n=1)
Publications included in qualitative synthesis n=9
Table 1: Thematic classification for the clinical recommendations in the included guidelines
Organization
The University of New South Wales (2013)
Essential
" […] requires", "there must be", "the clinician must [...]", "clinicians will [...]"
Recommended
"The clinician should [...]", "[…] should be recommended"
Dutch Orthopaedic Association (2014)
Industrial Insurance Chiropractic Advisory Committee (2014))
New York State Worker's Compensations Board (2013)
Washington State Department of Labor and industries (2013)
"[…] is mandatory"
____
"The provider must […]"
"Must or must be [...]"
"[...] is required", "clinicians will [...]",
"Primary indications are […]", "should be"
"The working group recommends […]", "[...] has the best chance of success", "[...] should be used", "[…] is advised", "[...] can be considered", "[...] is indicated", "it is preferable to [...]"
"[...] is recommended", "should consider [...]", "should include", "this is considered best practice to […]"
"Should or should be […]", "[...] is strongly preferred"
"The clinician should [...]”, “[…] should be recommended", "[...] are typically sufficient", "[...] is indicated"
"May be indicated", "may be useful", "may use", "can be used"
"[…] may be used", "[...] can or may be considered"
"[…] may be helpful", "[…] may be beneficial", "[…] is useful in some circumstances", "[…] should be considered if", "[…] may be indicated"
"May be used", "It may be of value to [...]", "it may be useful", "can or can be [...]"
[...] may be used, "[...] may be offered", "[...] will be considered if", "[…] should be used if", "[…] is a treatment option if", "[...] is reasonable if"
"Not recommended", "may not be pertinent"
____
"[…] should not", "[...] is not indicated", "will not [...]", "[...] is not recommended"
"[…] do not appear to add benefits", "it is recommended not to use […]"
"[…] should not", "[...] is not indicated"," […] is not recommended"
"[…] should not", "[...] is not indicated", "will not [...]"
____
____
____
____
____
____
National University of Health Sciences (2008)
American Academy of Orthopaedic Surgeons (2010)
Colorado Department of Labor and Employment (2015)
American College of Radiology (2015)
"[…] is essential", "[…] is the most important feature"
"[…] must be"
"Must or must be [...]"
"We recommend [...]", "we suggest that […]"," […] is beneficial"
"Should implement […]", "Is recommended", "should incorporate […]", "[…] should be considered", "strongly consider […]", "[…] is generally accepted"
"Not initially indicated", "not routinely indicated", "special investigation", "[…] is typically not useful"
"[...] is an option"
"[…] may be recommended", "[…] may be indicated", "[…] is not necessary if", "may include […]", "[…] is not necessarily contraindicated"
"Indicated", "[…] is indicated before other […]"
May be recommended
"May include", "may consider or may be […]" , "can or can be [...]"
Not recommended
"[...] is not indicated", "should not", "should refrain from using [...]"
____
"[…] not be performed", "we suggest surgeons not use […]"
No recommendation
"No clinical recommendations were made"
____
"We can not recommend for or against […]"
Table 2: Clinical practice guidelines characteristics
Organization
The University of New South Wales (2013)
National University of Health Sciences (2008)
American Academy of Orthopaedic Surgeons (2010) Colorado Department of Labor and Employment (2015)
American College of Radiology (2015)
Dutch Orthopaedic Association (2014)
Title
Clinical practice guidelines for the management of rotator cuff syndrome in the workplace Diagnostic imaging guideline for musculoskeletal complaints in adults – an evidence-based approach Optimizing the management of rotator cuff problems guideline and evidence report Shoulder Injury Medical Treatment Guidelines Practice parameter for the performance and interpretation of magnetic resonance imaging (MRI) of the shoulder Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association
Population of injured workers specifically covered
Development involved a systematic review
Development involved a systematic consultation of stakeholders
Declaration of competing interests mentioned
Methods for formulating the recommendation are described
Presence of an explicit link between the evidence and the recommendations
Externally reviewed
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not specified
No
No
Not specified
Not specified
No
Not specified
Not specified
No
No
No
Not specified
No
Yes
Not specified
No
Yes
Yes
Not specified
Industrial Insurance Chiropractic Advisory Committee (2014)
Conservative Care Options for Work-Related Mechanical Shoulder Conditions
Yes
Yes
Not specified
No
No
No
Not specified
New York State Worker's Compensations Board (2013)
New York Shoulder Injury Medical Treatment Guidelines
Yes
No
Not specified
No
No
No
Not specified
Yes
Yes
Not specified
No
No
No
Not specified
Washington State Department of Labor and industries (2013)
Medical Treatment Guidelines
Evaluation, treatment and return to work for shoulder rotator cuff disorders: a systematic review of clinical practice guidelines and semantic analyses of recommendations
Evaluation, treatment and return to work for shoulder rotator cuff disorders: a systematic review of clinical practice guidelines and semantic analyses of recommendations
S0003-9993(20)30030-7
DOI:
https://doi.org/10.1016/j.apmr.2019.12.017
Reference:
YAPMR 57759
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 10 December 2019 Accepted Date: 12 December 2019
Please cite this article as: Doiron-Cadrin P, Lafrance S, Saulnier M, Cournoyer É, Roy J-S, Dyer J-O, Frémont P, Dionne C, MacDermid JC, Tousignant M, Rochette A, Lowry V, Bureau NJ, Lamontagne M, Coutu psy M-F, Lavigne P, Desmeules F, Shoulder rotator cuff disorders: a systematic review of clinical practice guidelines and semantic analyses of recommendations, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2020), doi: https://doi.org/10.1016/j.apmr.2019.12.017. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc. on behalf of the American Congress of Rehabilitation Medicine
RC DISORDERS GUIDELINES SYSTEMATIC REVIEW
Shoulder rotator cuff disorders: a systematic review of clinical practice guidelines and semantic analyses of recommendations Patrick Doiron-Cadrin PT, M.Sc.1, Simon Lafrance PT, M.Sc.1, Marie Saulnier, PT, M.Sc.1, Émie Cournoyer B.Sc.1, Jean-Sébastien Roy PT, Ph.D.2, 3, Joseph-Omer Dyer PT, Ph.D.4, Pierre Frémont MD, Ph.D.2, Clermont Dionne OT, Ph.D. 2, 5, Joy C. MacDermid PT, Ph.D.6, Michel Tousignant PT, Ph.D.7, Annie Rochette OT, Ph.D.4, 8, Véronique Lowry PT, M.Sc.1, Nathalie J. Bureau MD, M.Sc.9, 10, Martin Lamontagne MD11, Marie-France Coutu psy, Ph.D.13, Patrick Lavigne, MD 1, 14, François Desmeules PT, Ph.D.1, 4
1. Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montreal, Quebec, Canada 2. Department of Rehabilitation, Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada 3. Centre for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Quebec City, Quebec, Canada 4. School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada 5. Centre de recherche du CHU de Québec - Université Laval, Quebec City, Quebec, Canada 6. School of Physical Therapy, Western University, London, Ontario, Canada 7. School of Rehabilitation, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada 8. Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montreal, Quebec, Canada 9. Department of Radiology, Oncology and Nuclear Medicine, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada 10. University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada 11. Department of Medicine, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada 12. School of Public Health, University of Montreal, Montreal, Quebec, Canada 13. Centre for Work Disability Prevention and Rehabilitation (CAPRIT), Charles-Le Moyne Hospital Research Centre affiliated with Université de Sherbrooke, Longueuil, Canada 14. Department of Surgery, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
Corresponding author: François Desmeules, PT, Ph. D. University of Montreal Maisonneuve-Rosemont Research Centre 5415, boulevard de l’Assomption Montréal (Québec) H1T 2M4 Canada : [email protected]
FUNDING: This project was financially supported by the Institut de recherche Robert-Sauvé en santé et en sécurité du travail (# 2016-0029). The funding source had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.
2019-12-08
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1 2 3
Shoulder rotator cuff disorders: a systematic review of clinical practice guidelines and semantic analyses of recommendations
4 5
ABSTRACT
6 7
Objectives: To perform a systematic review of clinical practice guidelines (CPGs) and semantic analysis of
8
specific clinical recommendations for the management of rotator cuff disorders in adults.
9 10
Data sources: A systematic bibliographic search was conducted up until May 2018 in Medline, Embase
11
and PeDro databases, in addition to twelve clinical guidelines search engines listed on the AGREE Thrust
12
website.
13 14
Study selection: Nine CPGs on the management of rotator cuff disorders in adults and/or workers,
15
available in English or French and published from January 2008 onward, were included and screened by
16
two independent reviewers.
17 18
Data extraction: CPGs methodology was assessed with the AGREE II tool. A semantic analysis was
19
performed to compare the strength of similar recommendations based on their formulation. The
20
recommendations were categorized in a standardized manner considering the following four levels:
21
“Essential”, “Recommended”, “May be recommended” and “Not recommended”.
22 23
Data synthesis: Methodological quality was considered high for three CPGs and low for six. All CPGs
24
recommended active treatment modalities, such as an exercise program in the management of rotator
25
cuff disorders. Acetaminophen and/or NSAIDs prescription and corticosteroid injections were presented
26
as modalities that may be recommended to decrease pain. Recommendations related to medical
27
imagery and surgical opinion varied among the guidelines. The most commonly recommended return to
28
work strategies included intervening early, use of a multidisciplinary approach and adaptation of work
29
organization.
30 31
Conclusions: Only three CPGs were of high quality. The development of more rigorous CPGs is 2019-06-03
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warranted.
33 34
KEYWORDS
35
Rotator Cuff, Evaluation, Treatment, Tendinopathy, Tendon Tear, Return-to-Work, Systematic Review,
36
Qualitative Analysis, Shoulder Impingement Syndrome, Shoulder pain
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LIST OF ABBREVIATION
38
CPGs: Clinical practice guidelines
39
GRADE: Grading of Recommendations Assessment, Development, and Evaluation
40
MRI: Magnetic resonance imaging
41
NSAID: Nonsteroidal anti-inflammatory drug
42
NHMRC: National Health and Medical Research Council
43
RC: Rotator cuff
44
RTW: Return to work
45
SIGN: Scottish Intercollegiate Guidelines Network
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46
Rotator cuff (RC) disorders are the most frequent group of pathologies affecting the shoulder
47
and represent 50% to 85% of shoulder conditions treated by health professionals (1). This group of
48
pathology includes tendinopathies, partial tears and full-thickness tears of one or more tendons of the
49
rotator cuff (2).
50
The point prevalence of shoulder pain varies from 6.9 to 26% in the general population and
51
increases with aging (3). The prevalence of RC abnormalities in the general population increase with
52
aging, reaching an estimate of 31% in adults between 60 and 69 years old and 65% in adults overs 80
53
years old (4). Without appropriate care, individuals with rotator cuff disorders are subject to persistent
54
pain over time (5). This situation highlights the importance of establishing a rapid and valid diagnosis,
55
while offering the best available evidence-based care to individuals of working age presenting with such
56
conditions.
57
Clinical practice guidelines (CPGs) have been developed for the treatment of rotator cuff
58
disorders in adults (6-14). CPGs are generally referred as “systematically developed statements to assist
59
practitioner decisions about appropriate health care for specific clinical circumstances” (15). While CPGs
60
offer a convenient way to transfer scientific knowledge into clinical practice for healthcare practitioners,
61
adherence to their content and recommendations remains suboptimal (16, 17).
62
Barriers to the uptake of clinical recommendations include, the use of weak or conflicting
63
evidence, the lack of applicability and ambiguous formulation have already been identified (18). In
64
addition, the methodological quality of clinical guidelines has been shown to vary widely from an
65
organization to another (19, 20) and conflicting recommendations on a same topic can be a source of
66
confusion for health-care providers, patients and stakeholders (21-23). Nonetheless, multiple systems to
67
grade evidence are currently used by authoring organizations to classify the strength and/or the level-of-
68
evidence underlying clinical recommendations, while other institutions simply do not present grading
69
scales at all (24). Comparing clinical recommendations from different publications can thus represent a
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70
challenge. Qualitative thematic analysis of recommendations, based on the choice of semantic fields for
71
the formulation of recommendations rather than on a specific scale, can be helpful to overcome this
72
obstacle (25).
73
The aim is therefore to systematically review and critically appraise recent CPGs developed for
74
the management of rotator cuff disorders in adult, including evaluation, conservative and surgical
75
treatments as well as return to work strategies and to synthesize, through a semantic analysis current
76
evidence regarding the most consensual recommendations for rotator cuff disorders in adults.
77 78
METHODS
79
Identification, Selection of Guidelines and Quality Appraisal
80
A systematic bibliographic search was conducted up until May 2018, in Medline, Embase and
81
PeDro databases, in addition to twelve clinical guidelines search engines listed on the AGREE Thrust
82
website (see Figure 1). The keywords “shoulder”, “tendinopathy”, “rotator cuff”, “shoulder girdle”,
83
“upper limb” and “guidelines” were used to identify clinical guidelines (exact search is presented in
84
supplementary material). A manual search was also conducted through the identified guidelines
85
reference lists. Inclusion criteria for the clinical guidelines were: 1-containing recommendations on the
86
evaluation, treatment and/or return-to-work of adults or workers presenting a rotator cuff disorder; 2-
87
published recently (from January 2008 onward); 3- available in English or French. Clinical guidelines with
88
an exclusive scope on other shoulder pathologies such as adhesive capsulitis, shoulder fractures, labral
89
tears, arthritis or other shoulder disorders were excluded.
90
References were retrieved from databases and duplicates were removed. Two reviewers (PDC
91
and MS) screened titles and abstracts from the reference list in order to assess eligibility for inclusion.
92
Full texts were retrieved and assessed (PDC and MS). Reference lists from full-text documents were
93
checked for relevant citations. In case of disagreement, a consensus was reached between the pair of 2019-06-03
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reviewers at all stages process. When two or more guidelines from the same organization and the same
95
committee were identified, only the most recent was included.
96
Clinical guidelines characteristics were extracted by two reviewers (PDC and SL), using a
97
standardized form documenting titles, organizations, year of publication, reported objectives and
98
presence of recommendations specifically targeted to injured workers. Methodological elements such as
99
the professional groups involved, the presence of a systematic review of the literature, the declaration of
100
competing interests, the description of the methods to formulate the recommendations, the presence of
101
an explicit link between the scientific evidence and the recommendations, and the presence of an
102
external revision process were also compiled.
103
Clinical guidelines methodological quality was assessed by pairs of reviewers (PDC, EC, MS, SL)
104
based on the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. The AGREE II
105
appraisal tool comprises 23 key items rated on a 7-point scale (1—Strongly disagree to 7—Strongly
106
agree). The items are summarized in six domains (Scope and Purpose, Stakeholder involvement, Rigour
107
of Development, Clarity of Presentation, Applicability, and Editorial Independence). This validated tool
108
has been widely used to evaluate the methodology quality of clinical guidelines worldwide (26). The final
109
score for each clinical guideline was obtained by means between pairs of reviewers as recommended by
110
the AGREE instrument methodology (27).
111 112 113
Semantic Analysis and Synthesis of Recommendations Clinical recommendations were extracted from the clinical guidelines, coded and pooled by a
114
reviewer (PDC) into nine categories: clinical evaluation, medical imaging, medication for RC
115
tendinopathy, medication for RC full-thickness tears, rehabilitation modalities for RC tendinopathy,
116
rehabilitation modalities for RC full-thickness tears, surgical interventions for RC tendinopathy, surgical
117
interventions for RC full-thickness tears and return-to-work strategies for all RC disorders. The categories
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118
were then refined and confirmed by a second reviewer (SL).
119
A semantic analysis was performed to compare the strength of similar recommendations based
120
on their formulation (28, 29). The recommendations were categorized according to their strength in a
121
standardized manner considering the following four levels: “Essential”, “Recommended”, “May be
122
recommended” and “Not recommended” (see Table 1). The analysis was based on the semantic fields for
123
the terms “obligation”, “recommendation” and “possibility” for the recommended activities, modalities
124
or strategies (30, 31). All the non-recommended activities, modalities or strategies were categorized as
125
“not recommended” (Table 1).
126
All recommendations presented in the included CPGs, as well as the accompanying explanations,
127
were subject to the semantic analysis and a second reviewer (SL) validated data results. A consensus was
128
needed between reviewers; a third reviewer was available to discuss any disagreement.
129 130
RESULTS
131
Included Guidelines Characteristics
132
Ten clinical guidelines were identified during the systematic review (6, 7, 9, 11, 14, 32-36). One
133
guideline was later excluded because the complete version was only available in Danish (36). Data were
134
extracted from the remaining nine guidelines (Figure 1). All the guidelines were published between 2008
135
and 2015 in English, seven guidelines covered clinical evaluation activities or strategies (7, 9, 11, 14, 32-
136
34), eight guidelines covered medical imaging prescriptions (7, 9, 11, 14, 32-35), seven guidelines
137
covered medication prescriptions, rehabilitation modalities and surgery or surgical techniques (6, 7, 9,
138
11, 14, 32, 35), and six guidelines contained recommendations on return to work strategies (7, 9, 11, 14,
139
32, 35).
140 141
The CPGs characteristics and AGREE II composite domain scores are presented in table 2. Three CPGs were considered of high methodological quality (6, 9, 33) while six were considered of lower 2019-06-03
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142
methodological quality (7, 11, 14, 32, 34, 35). A systematic review of the relevant literature was involved
143
in the development of seven guidelines (6, 7, 9, 14, 32, 33, 35). An explicit link between the scientific
144
evidence and the recommendations was present in four guidelines (6, 7, 9, 33). Three guidelines included
145
a declaration of conflicting interests, involved a systematic consultation of stakeholders and explicitly
146
stated that an external revision process was performed (6, 9, 33).
147 148 149
Assessment of Shoulder Pain Thirteen clinical evaluation activities or strategies were identified in seven guidelines (9, 11, 14,
150
32-35). Taking a medical history, performing a physical examination, identifying red and yellow flags,
151
measuring shoulder range of motion and strength and using validated questionnaires to assess patient’s
152
condition were considered essential elements or were recommended in all guidelines. Using shoulder
153
specific clinical tests and contacting an interpreter if needed were either “recommended” or “may be
154
recommended”, while performing a functional capacity evaluation and use of local anesthetic injections
155
in the subacromial space for diagnostic purpose were considered as “may be recommended”, when the
156
subject was covered.
157 158
Medical Imaging for Rotator Cuff Disorders
159
Prescribing radiography for the initial assessment or during the follow-up of patients, diagnostic
160
ultrasound, magnetic resonance (MRI) and magnetic resonance arthrography (MRA) were considered as
161
“may be recommended”, when the subject was covered. Radiography was indicated at initial
162
consultation in the presence of a history of trauma (14, 32, 33) or if a diagnosis other than a RC disorder
163
was suspected after the clinical evaluation (9, 11, 14). At the follow-up, conventional radiography was
164
“recommended” in the absence of improvement after an adequate conservative treatment when
165
reviewed (7, 9, 11, 32, 33, 35). Diagnostic ultrasound was “recommended” in the absence of 2019-06-03
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improvement after conservative care (7, 11, 32, 33, 35), if there is a “lack of access to MRI” (9) or to
167
“rule-out a RC tear” in one guideline (32). MRI was “recommended” in the absence of improvement after
168
conservative care (9, 11, 32, 33), prolonged refractory or unexplained pain (34), significant weakness on
169
shoulder elevation or rotation (35), suspected RC tear (14) or if diagnostic ultrasound was inconclusive
170
(7). MRA was recommended to investigate a possible intra-articular lesion or an associated
171
glenohumeral instability (7, 11, 34, 35), for suspected partial RC tear (7, 34) or if the diagnosis was not
172
identified with standard imagery techniques (35).
173 174
Medication for Rotator Cuff Tendinopathy
175
Thirteen activities related to medication prescriptions for RC tendinopathy were identified
176
among a total of seven guidelines (6, 7, 9, 11, 14, 32, 35). Four guidelines did cover the prescription of
177
acetaminophen, which was “recommended” for mild or moderate pain in two guidelines (9, 11) and
178
“may be recommended” without specific indications in two others (14, 35). Seven guidelines covered
179
and considered the prescription of NSAIDS as “may be recommended” for the treatment of shoulder
180
pain without specific indications (6, 7, 9, 11, 14, 32, 35).
181
Corticosteroids injections were considered as “may be recommended” in all guidelines, when
182
reviewed, but indications varied substantially: in the presence of persistent pain after a conservative
183
treatment (7, 9), if there is a “positive response” to a diagnostic analgesic injection (11), in the absence
184
of response to “manual methods” (32) or was considered as “may be recommended” without any
185
specific indications in two guidelines (14, 35). Patient education regarding the prescribed medication was
186
recommended in three guidelines, but the content of the information to provide was not specified (7, 11,
187
35).
188 189
Medication for Rotator Cuff Full-Thickness Tear 2019-06-03
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Eleven activities related to medication prescriptions for RC full-thickness tears were identified
191
among a total of six guidelines (6, 9, 11, 14, 32, 35). Acetaminophen prescription was “recommended” in
192
two guidelines (9, 11) and as “may be recommended” without further details in two others (14, 35).
193
Indications for various medications varied substantially from a publication to another. Tramadol
194
was as “may be recommended” for “patients without prior opioid addiction” in one guideline (35) and if
195
there is “no response to manual methods” in another one (11). Opioids were as “may be recommended”
196
if regular assessments are possible, in one guideline (9), and in the presence of severe upper extremity
197
pain, in another one (35). Hypnotics were considered as “may be recommended” in case of sleep
198
disorders in two guidelines (11, 35)}. Muscle relaxant and anti-anxiety medications were covered in two
199
guidelines and subject to conflicting recommendations (not recommended vs. may be recommended)
200
(11, 35). Patient education regarding the prescribed medication was “recommended” in two guidelines,
201
but the content of the information to be provided was not specified (11, 35).
202 203
Corticosteroids injections were considered as “may be indicated” in a case of persistent pain after an adequate conservative treatment (9) and in the “absence of response to manual methods” (32).
204 205
Rehabilitation Modalities for Rotator Cuff Tendinopathy
206
Sixteen rehabilitation modalities or treatment approaches were identified among a total of
207
seven guidelines and exercise prescription was recommended in all of them (6, 7, 9, 11, 14, 32, 35).
208
Manual therapy modalities and psychosocial interventions were “recommended” or “may be
209
recommended” in a total of six guidelines (7, 9, 11, 14, 32, 35). Heat or cold applications, acupuncture,
210
TENS and using a multidisciplinary approach were reviewed in a total of six guidelines and defined as
211
“may be recommended” in all of them (6, 7, 9, 11, 32, 35). Taping, microwave diathermy and laser were
212
“not recommended” and reviewed in two guidelines (11, 35).
213 2019-06-03
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214 215
Rehabilitation Modalities for Full-Thickness Rotator Cuff Tear Fourteen rehabilitation modalities or treatment approaches were identified among a total of five
216
guidelines. Exercise prescription was “recommended” in three guidelines (9, 11, 14) and as “may be
217
recommended” in another one (35). Manual therapy modalities were “recommended” in one guideline
218
(14) and were as “may be recommended” in three others (9, 11, 35). Heat or cold applications,
219
acupuncture, therapeutic ultrasound, TENS, psychosocial interventions and using a multidisciplinary
220
approach were classified as “may be recommended” in three guidelines (9, 11, 35).
221 222
Interventions Related to Surgery or Other Medical Interventions for Rotator Cuff
223
Tendinopathy
224
Seven interventions related to surgery and surgical approaches were identified among a total of
225
six guidelines (7, 9, 11, 14, 32, 35). Referring for a surgical opinion was “recommended” in five
226
guidelines in varied circumstances: in the presence of a “significant activity limitation, participation
227
restriction and/or persistent pain after a nonsurgical treatment of three months” (9), in the “absence of
228
improvement after a three to six-month rehabilitation program” (35), if “pain is worsening after three to
229
six weeks or in the presence of inadequate improvement at 7-8 weeks” (32), if “no improvement with 6
230
weeks of conservative intervention and rehabilitation program” (11) and if “no improvement with
231
conservative intervention and rehabilitation program” (14). Acromioplasty was considered as an
232
intervention that may be indicated after an active rehabilitation program in three guidelines (11, 14, 35).
233
Recommendations for percutaneous lavage were present in four guidelines and were “may be indicated”
234
in the absence of improvement after conservative care in three guidelines (9, 14, 35), and without
235
additional details in another one (7). Both open and arthroscopic surgery approaches for the treatment
236
of RC tendinopathy were “recommended” in all four guidelines covering the subject (7, 9, 32, 35).
237
Platelet-rich plasma injections in the treatment of RC tendinopathy were considered as “may be 2019-06-03
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238
recommended” in one guideline (35) and were “not recommended” as a treatment in another one (32).
239 240
Interventions Related to Surgery for Rotator Cuff Full-Thickness Tear
241
Ten interventions related to surgery and surgical approaches were identified among a total of six
242
guidelines (7, 9, 11, 14, 32, 35). Referring for a surgical opinion was “recommended” in all six guidelines,
243
but in various circumstances: “in the presence of a full-thickness tear” (6, 9, 11), in the presence of an
244
“acute full-thickness RC tear of >1 cm or no response to a conservative treatment for tears <1 cm” (35), if
245
a RC tear is suspected with no response to four to six weeks of “manual methods” (32) and in the
246
presence of a symptomatic full-thickness RC tear or after a conservative treatment in the presence of a
247
chronic tear and for patients of 65 years and older (14). Performing an acromioplasty in conjunction with
248
a RC repair was “not recommended” in all three guidelines covering the subject (6, 14, 35). Performing a
249
RC repair by single vs. double rows, or by open surgery vs. arthroscopy were equally recommended in
250
three guidelines (9, 14, 35). Performing a graft was also “not recommended” based on recommendations
251
in two guidelines (14, 35).
252 253 254
Return-to-Work Strategies for Rotator Cuff Disorders Eleven interventions or strategies related to return to work (RTW) were identified among a total
255
of six guidelines (7, 9, 11, 14, 32, 35). The most commonly recommended return to work strategies
256
included intervening early, use of a multidisciplinary approach and adaptation of work organization.
257
Intervening early, establishing a RTW plan using shared decision-making process, maintaining
258
communication between the worker and the employer, establishing realistic goals for RTW were
259
“recommended” or considered “essential” in all guidelines that covered the subject (9, 11, 14, 35). All
260
other interventions or strategies were either “recommended”, or “may be recommended”, when
261
covered and details of these interventions are presented in the Supplementary Material (7, 9, 11, 14, 32, 2019-06-03
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262
35).
263 264
DISCUSSION
265
The aim of this systematic review was to systematically review and critically appraise recent CPGs
266
developed for the management of rotator cuff disorders in adults, including evaluation, conservative and
267
surgical treatments. To our knowledge, this review is the first to use a semantic analysis approach to
268
synthesize the published recommendations for this population.
269
Among the guidelines identified through our systematic search, publications from three
270
organizations stood out for their methodological quality: the University of New South Wales (9), the
271
American Academy of Orthopaedic Surgeons (6) and the National University of Health Sciences (33)
272
guidelines. The development process for those clinical guidelines included systematic reviews and
273
consultation of the stakeholders, presented a statement on conflicts of interests and explicit methods for
274
formulating the recommendations, in addition to an external review. Those three guidelines also
275
systematically tended to score higher for all the other AGREE II domains. Some of the AGREE domains,
276
like “Applicability”, “Development” and “Independence”, systematically presented very low scores
277
among the other guides.
278
Concerns about the overall methodological quality of clinical guidelines have been raised before
279
(37). This review tends to demonstrate that improvements in clinical guideline development and
280
publication process are still to be expected nowadays for the guidelines covering the evaluation, the
281
treatment and the return-to-work of adults presenting a RC disorder.
282
The qualitative analysis presented in this systematic review underlines that many of the currently
283
published recommendations covering evaluation, treatment or return-to-work strategies with adults
284
presenting a RC disorder are often inconsistent. Some interventions were, however, recommended on a
285
more consensual basis, such as all clinical evaluation activities, which were either considered “Essential”, 2019-06-03
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286
“Recommended” or “May be recommended”, although the exact content of a valid physical examination
287
was not precisely defined. Prescribing exercise for the treatment of RC tendinopathy and RC full-
288
thickness tear was universally recommended among the guidelines covering this subject. Manual therapy
289
was either considered “recommended” or “may be recommended”, theses recommendations are in line
290
with the results of a systematic review published by Desjardins-Charbonneau et al., (38) which concluded
291
that manual therapy may decrease pain in adults with RC tendinopathy. In the same order of ideas, a
292
Cochrane review reported that the effect of manual therapy and exercise may be similar to those of
293
corticosteroid injections and subacromial decompression surgery, but may not lead to clinically
294
important effect when compared to a placebo (39). In all guidelines, prescribing acetaminophen, NSAIDS
295
and corticosteroid injections were presented as “may be recommended” options for the treatment RC
296
tendinopathy and RC full-thickness tear. The effect of platelet-rich plasma injections in the treatment of
297
RC tendinopathy remained unclear. A meta-analysis reported that platelet-rich plasma injections
298
significantly reduce pain and disability when compared to a placebo injection or to dry needling (40).
299
However, this review only included two RCTs on RC tendinopathy and could not conclude if the effect
300
was clinically important or not.
301
Regarding surgical interventions, performing an acromioplasty for the treatment of RC
302
tendinopathy was presented as a treatment option after the failure of conservative treatments,
303
however, it is important to highlight that these CPGs were published before two RCTs that report no
304
benefit of arthroscopic subacromial decompression compared to a placebo surgery and no clinically
305
important difference when compared to no intervention or exercise therapy (41, 42). Routine
306
acromioplasty during a RC repair was universally not recommended. Single row sutures, double row
307
sutures, open approach and arthroscopy were presented as equally effective in all guidelines for the
308
reparation of RC full-thickness tears. All the identified return-to work strategies were either
309
“Recommended” or “May be recommended” in all guidelines that covered the subject.
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310
On the other hand, other recommendations were subject to high heterogeneity across the
311
retrieved guidelines. For instance, indications for medical imaging tests like radiography, diagnostic
312
ultrasound, MRI and MRA varied among CPGs. This could be explained by comparable diagnostic
313
capabilities among diagnostic ultrasound, MRI and MRA for RC tear, with slightly higher sensitivity and
314
sensibility for MRA (43). Indications to refer for a surgical opinion also varied among the CPGs, which
315
could be explained by a lack of evidence regarding surgical indications for RC disorders (44-46).
316
Therapeutic ultrasounds were “may be recommended” for the treatment of RC tendinopathy in some
317
guidelines, and “not recommended” in others. Those conflicting recommendations can render the
318
clinical decision-making process rather difficult for the healthcare professionals.
319
Another issue is the use of multiple scales to appraise the quality of the evidence and the
320
strength of recommendations such as National Health and Medical Research Council (NHMRC),
321
Scottish Intercollegiate Guidelines Network (SIGN), or Grading of Recommendations Assessment,
322
Development, and Evaluation (GRADE) scales. This situation clearly represents a challenge even if several
323
guidelines gave adequate information on the utilization of the appraisal scales. Still, four of the retrieved
324
guidelines in this review do not explicitly state a standardized appraisal scale (11, 14, 32, 34). This
325
impediment has been encountered by authors of other clinical guidelines systematic reviews and
326
creative approaches, such as creating a new scale or converting the recommendations to a unified level
327
of evidence grading scale, have been employed (19, 22). The qualitative thematic analysis presented in
328
this systematic review allowed a comparison between the complete set of currently published
329
recommendations, which would not have been possible otherwise. Similar approaches to ours, based on
330
an analysis of the formulation rather than a strength-of-recommendation or level-of-evidence scale, has
331
been used in previous clinical guidelines systematic reviews (47, 48).
332 333
Those findings thus underline an urge for standardizing and simplifying the formulation of clinical recommendations among authoring organizations. While clinical guidelines aim to “assist practitioner
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334
and patient decisions about appropriate healthcare for specific clinical circumstances” (15), an explicit
335
link between scientific evidence and recommendations remains essential to allow clinicians, stakeholders
336
and consumers to evolve in an evidence-based practice framework (49). Furthermore, ambiguous
337
recommendation formulations, such as “It is recommended that by using patient feedback and response
338
as a guide, increasing grades of amplitude may be applied” (32), were present in several guidelines and
339
could be confusing for the reader. It has been demonstrated that recommendations formulated in a
340
simple manner are associated with a better uptake by clinicians (50). Clinical recommendations should
341
thus be formulated in that sense.
342
Furthermore, most of the identified guidelines were based on a biomedical model. Several
343
studies and systematic reviews have recognized the effectiveness and cost-effectiveness of
344
interdisciplinary interventions that included support during return to work (51-55). Work disability field
345
literature also highlights the importance of communication between patients and healthcare
346
professionals, as it can influence the recovery trajectory for injured workers (56). Surprisingly, such
347
interventions were scarcely covered and discussed in the retrieved guidelines.
348
This review presents many strengths, among which an extensive systematic search in three
349
major scientific databases, in addition to twelve other guideline databases and medical societies’
350
websites. The validated AGREE II appraisal instrument was also used to compare the methodological
351
quality between the guidelines. Since no cut-off score has been identified for the AGREE II instrument,
352
methodological items were extracted from the different domains to allow an objective comparison of
353
the identified guidelines.
354
Our review also presents some limits. Since only guidelines published in English or French were
355
retained, other relevant publications could have been missed. The excluded guideline by the Danish
356
Authority is an example of this limitation (36). The fact that only two reviewers appraised the
357
methodological quality of the guidelines could also potentially impact the results, since concerns about
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358
inter-reviewer fidelity have been raised for the AGREE instrument (24). Likewise, no verification upon the
359
quality or the sources for the scientific evidence underlying the clinical recommendations was sought.
360
Variations in the evidence could explain some discrepancies between the recommendations presented in
361
the included guidelines, but those analyses would not have been possible for all of them due to a lack of
362
methodological information and transparency.
363 364 365
CONCLUSIONS In this systematic review, a qualitative thematic analysis was used to compare recommendations
366
from nine clinical guidelines on the evaluation, treatment and the return-to-work of adults presenting a
367
shoulder RC disorder. Three clinical guidelines were considered of high methodological quality, while six
368
were considered of lower methodological quality. Prescribing exercise for the treatment of RC
369
tendinopathy was universally recommended. All identified clinical evaluation activities and all return-to-
370
work strategies were presented as modalities that may be recommended for that population. Indication
371
for medical imagery (radiography, diagnostic ultrasounds and MRI) and surgical opinion varied among
372
the guidelines. Since this can be confusing for healthcare professionals there is a need to standardize the
373
way clinical recommendations are formulated. The same applies to the reporting for strength and level
374
of evidence among guidelines. Enhancing the clinical guideline development process regarding the
375
applicability, the development and the declaration of competing interests are mandatory in order to
376
allow the health-care professionals to fully appraise and uptake their content.
377 378 379
AUTHORS’ CONTRIBUTIONS:
380
PDC designed the study protocol, performed the literature search, selected the articles of interest,
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381
performed the risk-of-bias analysis, extracted the data, led the interpretation of results, and wrote the
382
manuscript. SL participated in the selection of the articles, risk-of-bias analysis, data extraction, results
383
interpretation and writing the manuscript. MS and EC participated in risk-of-bias analysis, data extraction
384
and writing of the manuscript. JSR, JOD, PF, CD, MT, AR, VL, NJB, ML, MFC participated in the protocol
385
design, interpretation of results and reviewed the article. JCM participated in the protocol design and
386
reviewed the article. PL participated in the interpretation of results and reviewed the article. FD
387
participated in the design, interpretation of results, writing of the manuscript, managed the project and
388
is the corresponding author.
389 390 391 392
COMPETING INTERESTS The authors declare that they have no competing interests.
393 394 395
WORD COUNT: 4181 words
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396
TABLES AND FIGURES
397 398 399 400 401 402 403 404 405 406
Figure 1: Flow diagram for the systematic review selection progress Table 1: Thematic classification for the clinical recommendations in the included guidelines Table 2: Clinical guidelines characteristics Supplementary material 1: Clinical guidelines recommendations summary Supplementary material 2: Complete AGREE II scores for the retrieved guidelines Supplementary material 3: Systematic review search strategies for scientific databases
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drug prescription with clinical practice guidelines in older inpatients. Fundamental & clinical pharmacology. 2016;30(1):82-92. 18. Kastner M, Bhattacharyya O, Hayden L, Makarski J, Estey E, Durocher L, et al. Guideline uptake is influenced by six implementability domains for creating and communicating guidelines: a realist review. Journal of clinical epidemiology. 2015;68(5):498-509. 19. Larmer PJ, Reay ND, Aubert ER, Kersten P. Systematic review of guidelines for the physical management of osteoarthritis. Archives of physical medicine and rehabilitation. 2014;95(2):375-89. 20. Lin I, Wiles LK, Waller R, Goucke R, Nagree Y, Gibberd M, et al. Poor overall quality of clinical practice guidelines for musculoskeletal pain: a systematic review. Br J Sports Med. 2018;52(5):337-43. 21. Ferket BS, Grootenboer N, Colkesen EB, Visser JJ, van Sambeek MR, Spronk S, et al. Systematic review of guidelines on abdominal aortic aneurysm screening. Journal of vascular surgery. 2012;55(5):1296-304. e4. 22. Jolliffe L, Lannin NA, Cadilhac DA, Hoffmann T. Systematic review of clinical practice guidelines to identify recommendations for rehabilitation after stroke and other acquired brain injuries. BMJ open. 2018;8(2):e018791. 23. Paraskevas KI, Mikhailidis DP, Veith FJ. Comparison of the five 2011 guidelines for the treatment of carotid stenosis. Journal of vascular surgery. 2012;55(5):1504-8. 24. MacDermid JC, Brooks D, Solway S, Switzer-McIntyre S, Brosseau L, Graham ID. Reliability and validity of the AGREE instrument used by physical therapists in assessment of clinical practice guidelines. BMC Health Services Research. 2005;5(1):18. 25. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC medical research methodology. 2008;8(1):45. 26. Vlayen J, Aertgeerts B, Hannes K, Sermeus W, Ramaekers D. A systematic review of appraisal tools for clinical practice guidelines: multiple similarities and one common deficit. International Journal for Quality in Health Care. 2005;17(3):235-42. 27. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. Cmaj. 2010;182(18):E839-E42. 28. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006;3(2):77-101. 29. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qualitative health research. 2005;15(9):1277-88. 30. Hinkel E. The use of modal verbs as a reflection of cultural values. TESOL quarterly. 1995;29(2):325-43. 31. Rosenberg Lv. Do I have to? On the Expression of Degrees of Obligation in the Official English Version and the Dutch Translation of CEDAW 2013. 32. Industrial Insurance Chiropractice Advisory Committe. Conservative Care Options for Work-Related Mechanical Shoulder Conditions. Washington State Department of Labor and Industries; 2014. 33. Bussières AE, Peterson C, Taylor JA. Diagnostic imaging guideline for musculoskeletal complaints in adults—an evidence-based approach—part 2: upper extremity disorders. Journal of Manipulative & Physiological Therapeutics. 2008;31(1):2-32. 2019-06-03
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34. American College of Radiology. ACR–SPR–SSR practice parameter for the performance interpretation of magnetic resonance imaging of the shoulder. 2015. 35. Colorado Department of Labor and employment. Shoulder Injury Medical Treatment Guidelines. Colorado Department of Labor and employment; 2015. 36. Danish Health Authority. National clinical guideline on diagnostics and treatment of patients with selected shoulder conditions quick guide. 2016. 37. Shaneyfelt TM, Mayo-Smith MF, Rothwangl J. Are guidelines following guidelines?: The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. Jama. 1999;281(20):1900-5. 38. Desjardins-Charbonneau A, Roy J-S, Dionne CE, Frémont P, MacDermid JC, Desmeules F. The efficacy of manual therapy for rotator cuff tendinopathy: a systematic review and metaanalysis. journal of orthopaedic & sports physical therapy. 2015;45(5):330-50. 39. Page MJ, Green S, McBain B, Surace SJ, Deitch J, Lyttle N, et al. Manual therapy and exercise for rotator cuff disease. Cochrane Database of Systematic Reviews. 2016(6). 40. Tsikopoulos K, Tsikopoulos I, Simeonidis E, Papathanasiou E, Haidich A-B, Anastasopoulos N, et al. The clinical impact of platelet-rich plasma on tendinopathy compared to placebo or dry needling injections: A meta-analysis. Physical Therapy in Sport. 2016;17:87-94. 41. Beard DJ, Rees JL, Cook JA, Rombach I, Cooper C, Merritt N, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet. 2018;391(10118):329-38. 42. Paavola M, Malmivaara A, Taimela S, Kanto K, Inkinen J, Kalske J, et al. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial. bmj. 2018;362:k2860. 43. De Jesus JO, Parker L, Frangos AJ, Nazarian LN. Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis. American Journal of Roentgenology. 2009;192(6):1701-7. 44. Keener JD, Patterson BM, Orvets N, Chamberlain AM. Degenerative rotator cuff tears: refining surgical indications based on natural history data. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2019;27(5):156-65. 45. Oh LS, Wolf BR, Hall MP, Levy BA, Marx RG. Indications for rotator cuff repair: a systematic review. Clinical Orthopaedics and Related Research®. 2007;455:52-63. 46. Thorpe A, Hurworth M, O'Sullivan P, Mitchell T, Smith A. Rotator cuff disease: opinion regarding surgical criteria and likely outcome. ANZ journal of surgery. 2017;87(4):291-5. 47. Abbott AL, Paraskevas KI, Kakkos SK, Golledge J, Eckstein H-H, Diaz-Sandoval LJ, et al. Systematic review of guidelines for the management of asymptomatic and symptomatic carotid stenosis. Stroke. 2015;46(11):3288-301. 48. Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM, editors. A systematic review of recommendations and guidelines for the management of osteoarthritis: the chronic osteoarthritis management initiative of the US bone and joint initiative. Seminars in arthritis and rheumatism; 2014: Elsevier. 49. Rycroft‐Malone J, Seers K, Titchen A, Harvey G, Kitson A, McCormack B. What counts as evidence in evidence‐based practice? Journal of advanced nursing. 2004;47(1):81-90. 50. Michie S, Lester K. Words matter: increasing the implementation of clinical guidelines. 2019-06-03
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BMJ Quality & Safety. 2005;14(5):367-70. 51. Franche R-L, Cullen K, Clarke J, Irvin E, Sinclair S, Frank J, et al. Workplace-based returnto-work interventions: a systematic review of the quantitative literature. Journal of occupational rehabilitation. 2005;15(4):607-31. 52. Hlobil H, Staal JB, Spoelstra M, Ariëns GA, Smid T, van Mechelen W. Effectiveness of a return-to-work intervention for subacute low-back pain. Scandinavian journal of work, environment & health. 2005:249-57. 53. Loisel P, Lemaire J, Poitras S, Durand M-J, Champagne F, Stock S, et al. Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six year follow up study. Occupational and Environmental Medicine. 2002;59(12):807-15. 54. Schonstein E, Kenny DT. The value of functional and work place assessments in achieving a timely return to work for workers with back pain. Work. 2001;16(1):31-8. 55. Yassi A, Tate R, Cooper J, Snow C, Vallentyne S, Khokhar J. Early intervention for backinjured nurses at a large Canadian tertiary care hospital: an evaluation of the effectiveness and cost benefits of a two-year pilot project. Occupational Medicine. 1995;45(4):209-14. 56. Coutu M-F, Légaré F, Durand M-J, Corbière M, Stacey D, Bainbridge L, et al. Operationalizing a shared decision making model for work rehabilitation programs: a consensus process. Journal of occupational rehabilitation. 2015;25(1):141-52.
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Identification
Records identified through scientific databases Medline (n=288) Embase (n=358) Pedro (n=24)
Sceening
Records after duplicates removed n=495
Records after title and abstract screening n=2
Records identified through medical societies and guidelines databases proposed by the AGREE thrust National Guideline Clearinghouse (n=90) National Institute for Health and Care Excellence (n=250) Canadian Medical Association (n=3) Scottish Intercollegiate Guideline Network (n=57) National Health and Medical Research Council (n=2) eGuidelines (MGD Ltd.) (n=1) Guidelines-International-Network (n=312) TRIP database (n=362) Royal Dutch Society for Physical Therapy (n=15) Ministry of Health – New Zealand (n=0) American Academy of Orthopaedic Surgeons (n=27) GuidelineCentral (n= 67 566 results, research stopped after 4 pages of results)
Records retained after title and abstract screening n=11
Records after duplicate records removed n=10
Included
Elligibility
Full-text publications assessed for eligibility n=10
Records identified through manual searching n=0
Excluded Complete guide unavailable in English (n=1)
Publications included in qualitative synthesis n=9
Table 1: Thematic classification for the clinical recommendations in the included guidelines
Organization
The University of New South Wales (2013)
Essential
" […] requires", "there must be", "the clinician must [...]", "clinicians will [...]"
Recommended
"The clinician should [...]", "[…] should be recommended"
Dutch Orthopaedic Association (2014)
Industrial Insurance Chiropractic Advisory Committee (2014))
New York State Worker's Compensations Board (2013)
Washington State Department of Labor and industries (2013)
"[…] is mandatory"
____
"The provider must […]"
"Must or must be [...]"
"[...] is required", "clinicians will [...]",
"Primary indications are […]", "should be"
"The working group recommends […]", "[...] has the best chance of success", "[...] should be used", "[…] is advised", "[...] can be considered", "[...] is indicated", "it is preferable to [...]"
"[...] is recommended", "should consider [...]", "should include", "this is considered best practice to […]"
"Should or should be […]", "[...] is strongly preferred"
"The clinician should [...]”, “[…] should be recommended", "[...] are typically sufficient", "[...] is indicated"
"May be indicated", "may be useful", "may use", "can be used"
"[…] may be used", "[...] can or may be considered"
"[…] may be helpful", "[…] may be beneficial", "[…] is useful in some circumstances", "[…] should be considered if", "[…] may be indicated"
"May be used", "It may be of value to [...]", "it may be useful", "can or can be [...]"
[...] may be used, "[...] may be offered", "[...] will be considered if", "[…] should be used if", "[…] is a treatment option if", "[...] is reasonable if"
"Not recommended", "may not be pertinent"
____
"[…] should not", "[...] is not indicated", "will not [...]", "[...] is not recommended"
"[…] do not appear to add benefits", "it is recommended not to use […]"
"[…] should not", "[...] is not indicated"," […] is not recommended"
"[…] should not", "[...] is not indicated", "will not [...]"
____
____
____
____
____
____
National University of Health Sciences (2008)
American Academy of Orthopaedic Surgeons (2010)
Colorado Department of Labor and Employment (2015)
American College of Radiology (2015)
"[…] is essential", "[…] is the most important feature"
"[…] must be"
"Must or must be [...]"
"We recommend [...]", "we suggest that […]"," […] is beneficial"
"Should implement […]", "Is recommended", "should incorporate […]", "[…] should be considered", "strongly consider […]", "[…] is generally accepted"
"Not initially indicated", "not routinely indicated", "special investigation", "[…] is typically not useful"
"[...] is an option"
"[…] may be recommended", "[…] may be indicated", "[…] is not necessary if", "may include […]", "[…] is not necessarily contraindicated"
"Indicated", "[…] is indicated before other […]"
May be recommended
"May include", "may consider or may be […]" , "can or can be [...]"
Not recommended
"[...] is not indicated", "should not", "should refrain from using [...]"
____
"[…] not be performed", "we suggest surgeons not use […]"
No recommendation
"No clinical recommendations were made"
____
"We can not recommend for or against […]"
Table 2: Clinical practice guidelines characteristics
Organization
The University of New South Wales (2013)
National University of Health Sciences (2008)
American Academy of Orthopaedic Surgeons (2010) Colorado Department of Labor and Employment (2015)
American College of Radiology (2015)
Dutch Orthopaedic Association (2014)
Title
Clinical practice guidelines for the management of rotator cuff syndrome in the workplace Diagnostic imaging guideline for musculoskeletal complaints in adults – an evidence-based approach Optimizing the management of rotator cuff problems guideline and evidence report Shoulder Injury Medical Treatment Guidelines Practice parameter for the performance and interpretation of magnetic resonance imaging (MRI) of the shoulder Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association
Population of injured workers specifically covered
Development involved a systematic review
Development involved a systematic consultation of stakeholders
Declaration of competing interests mentioned
Methods for formulating the recommendation are described
Presence of an explicit link between the evidence and the recommendations
Externally reviewed
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not specified
No
No
Not specified
Not specified
No
Not specified
Not specified
No
No
No
Not specified
No
Yes
Not specified
No
Yes
Yes
Not specified
Industrial Insurance Chiropractic Advisory Committee (2014)
Conservative Care Options for Work-Related Mechanical Shoulder Conditions
Yes
Yes
Not specified
No
No
No
Not specified
New York State Worker's Compensations Board (2013)
New York Shoulder Injury Medical Treatment Guidelines
Yes
No
Not specified
No
No
No
Not specified
Yes
Yes
Not specified
No
No
No
Not specified
Washington State Department of Labor and industries (2013)
Medical Treatment Guidelines
Evaluation, treatment and return to work for shoulder rotator cuff disorders: a systematic review of clinical practice guidelines and semantic analyses of recommendations
Evaluation, treatment and return to work for shoulder rotator cuff disorders: a systematic review of clinical practice guidelines and semantic analyses of recommendations