Background
Methods
Criteria for considering studies for this review
Types of studies
Types of participants
Types of interventions
Types of outcome measures
Search methods for identification of studies
Data collection and analysis
Selection of studies
Data extraction and management
Risk of bias assessment
Risk of bias | Across studies | Interpretations | Considerations | GRADE assessment |
---|---|---|---|---|
Low risk of bias. | Most information is from studies at low risk of bias. | Plausible bias unlikely to seriously alter the results. | No apparent limitations. | No serious limitations, do not downgrade. |
Unclear risk of bias. | Most information is from studies at low or unclear risk of bias. | Plausible bias that raises some doubt about the results. | Potential limitations are unlikely to lower confidence in the estimate of effect. | No serious limitations, do not downgrade. |
Potential limitations are likely to lower confidence in the estimate of effect. | Serious limitations, downgrade one level. | |||
High risk of bias. | The proportion of information from studies at high risk of bias is sufficient to affect the interpretation of results. | Plausible bias that seriously weakens confidence in the results. | Crucial limitation for one criterion, or some limitations for multiple criteria, sufficient to lower confidence in the estimate of effect. | Serious limitations, downgrade one level |
Crucial limitation for one or more criteria sufficient to substantially lower confidence in the estimate of effect. | Very serious limitations, downgrade two levels. |
Best evidence synthesis
Underlying methodology | Quality rating |
---|---|
Randomized trials; or double-upgraded observational studies. | High |
Downgraded randomized trials; or upgraded observational studies. | Moderate |
Double-downgraded randomized trials; or observational studies. | Low |
Triple-downgraded randomized trials; or downgraded observational studies; or case series/case reports. | Very low |
Strong evidence | Provided by consistenta statistically significant findings in outcome measures in at least two high quality RCTsb
|
Moderate evidence | Provided by statistically significant findings in outcome measures in at least one high quality RCTb
or Provided by consistenta, statistically significant findings in outcome measures in at least two medium quality RCTsb
|
Limited evidence | Provided by statistically significant findings in at least one medium quality RCTb
or Provided by consistenta, statistically significant findings in outcome measures in at least two low quality RCTsb
|
No or insufficient evidence | If results of eligible studies do not meet the criteria for one of the levels of evidence listed above (e.g. no statistically significant findings) or In case of conflicting (statistically significant positive and statistically significant negative) results among RCTs or In case of no eligible studies |
Data synthesis and analysis
Results
Selection of studies
Study | Method | Participants | Outcome measures | Results/comments | Key domains | Score | Quality |
---|---|---|---|---|---|---|---|
Baskurt 2011 [54] | Randomized by simple random table. |
n = 40, 13 male, 27 female.
24–71 year. with a mean age of 51.
| Measured before and after intervention. Pain:VAS ROM: Goniometer Strength: Hand held dynamometer Function and QoL: WORC. Clinical tests: Joint Position Sense and Lateral Scapular Slide Test | Patients outcomes improved statistically in both groups (P < 0.05). No significant difference between groups in all parameters (P > 0.05) except muscle strength for lower trapezius and supraspinatus and clinical tests (P < 0.05). Comments: Missing P-values and CI in results section. No protocol registered. | Low risk: Randomization Drop-out rate Intention-to-treat Unclear risk: Allocation Compliance High risk: Other bias (sample size) | High risk (downgrade 1) | Moderate |
Dilek 2016 [57] | Randomized using block randomization. |
n = 63, 21 male, 42 women.
25–65 years. with a mean age of 49.13.
Mean duration of symptoms: approx. 17 months.
| Measured at baseline, 6 and 12 weeks. Pain: VAS ROM: Goniometer Strength: Isokinetic dynamometer system (Cybex Norm) Function and QoL: WORC and ASES | Both groups improved significantly in ROM, pain scores, isometric strength in all angles, Sense of kinesthesia at 0° ER, ASES and WORC (P < 0.05). No significant difference was found between groups in any of the parameters (P > 0.05). Comments: No protocol registered. | Low risk: Randomization Allocation Drop-out rate Intention-to-treat Unclear risk: Compliance High risk: Other bias (sample size) | High risk (downgrade 1) | Moderate |
Martins 2012 [58] | Unclear randomization |
n = 18, nursing professionals with age ranging from 30 to 50+ yrs.
16 subjects completed the study consisting of 2 male and 14 females. (no information on gender n = 2)
| Pain: VNS Function and QoL: WORC | Both groups exhibited significant reduction in pain scores (P < 0.05), however, no significant differences between groups. Only the intervention group improved WORC scores significantly. Comments: Outcomes of pain was less well presented and reduces transparency of data. | Low risk: Allocation Drop-out rate Intention-to-treat Compliance Unclear risk: Randomization High risk: Other bias (sample size) | High risk (downgrade 1) | Moderate |
Mulligan 2016 [53] | Randomized using blind draw. |
n = 50, 14 male and 26 females, (no information on gender n = 10)
| Measured at baseline, 4 weeks, 8 weeks, 16 weeks Pain: NPRS Function and QoL: ASES; GPF; GROC. | No significant between group and time. Both groups exhibited significant reduction in pain scores and function. However, no significant differences between groups. Comments: Protocol registered. Unclear reporting of co-interventions. | Low risk: Randomization Drop-out rate Intention-to-treat Allocation Unclear risk: Compliance High risk: Other bias (sample size) | High risk (downgrade 1) | Moderate |
Struyf 2013 [55] | Randomized using closed envelopes. |
n = 22, 10 male and 12 females. Aging from 30 to 61 years with a mean age of 45.8.
| Measured at baseline, after nine sessions (4–8 weeks) and 12 weeks Post treatment. Pain:VAS and VNRS Function and QoL: SDQ Clinical measures: Strength: handheld Dynamometer, Impingement test VAS Hawkins, Empty Can or Neer tests. Acromial distance, pectoralis minor length, scapula upward rotation and kinetic medial rotation test. | After nine sessions the Experimental group demonstrated significant effect on self-reported disability compared to the Control group (P = 0.025). Both groups increased from baseline in all outcomes measured (P < 0.05). No significant differences between group for strength or clinical measures, with exception for VAS by Neers test (p = 0.02) Comments: The protocol states that outcomes will be measured after 6 months. It is reported interim analysis was planned, however, is not mentioned in the protocol. | Low risk: Randomization Allocation Intention-to-treat Drop-out rate Unclear risk: Compliance High risk: Other bias (sample size and interim analyze) | High risk (downgrade 1) | Moderate |
Wang 2006 [56] | Randomized using pre-prepared sealed envelopes. |
n = 38, aging from 26 to 68 years. with a mean age of 44.6. Of the 38 subjects, 30 were analyzed consisting of 15 male and 15 female.
| Measured at baseline, 4 and 8 weeks. Pain: VAS Function and QoL: FLEX-SF ROM: Goniometer Strength: handheld dynamometer | No significant interaction between group and time. Both groups had significant improvements in regards to pain, function and muscle strength. FLEX-SF improved significantly after 8 weeks. Pain improved significantly after 4 and 8 weeks. Comments: No protocol registered. No gender distribution of the included subjects. | Low risk: Randomization Intention-to-treat Compliance Unclear risk: Allocation High risk: Drop-out rate Other bias (sample size) | High risk (downgrade 2) | Low |
Description of studies
Description of interventions
Risk of bias assessment and quality rating
Best evidence synthesis
Outcome | Inter-group effectivenessa
| Best evidence synthesis |
---|---|---|
Pain | Yes (moderate [55]) | Insufficient (conflicting) evidence |
Function | Yes (moderate [55]) | Insufficient (conflicting) evidence |
General strength | Yes (moderate [54]) | Insufficient (conflicting) evidence |
aScapular-stabilizers | Yes (moderate [54]) No (low [56]) | Limited evidence |
aProprioception and clinical tests | Yes (moderate [54]) | Insufficient evidence |
Range of motion | No evidence |