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The Cochrane Database of Systematic... Jun 2022Fractures of the proximal humerus, often termed shoulder fractures, are common injuries, especially in older people. The management of these fractures varies widely,... (Review)
Review
BACKGROUND
Fractures of the proximal humerus, often termed shoulder fractures, are common injuries, especially in older people. The management of these fractures varies widely, including in the use of surgery. This is an update of a Cochrane Review first published in 2001 and last updated in 2015.
OBJECTIVES
To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registries, and bibliographies of trial reports and systematic reviews to September 2020. We updated this search in November 2021, but have not yet incorporated these results.
SELECTION CRITERIA
We included randomised and quasi-randomised controlled trials that compared non-pharmacological interventions for treating acute proximal humeral fractures in adults. DATA COLLECTION AND ANALYSIS: Pairs of review authors independently selected studies, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome. We prepared a brief economic commentary for one comparison.
MAIN RESULTS
We included 47 trials (3179 participants, mostly women and mainly aged 60 years or over) that tested one of 26 comparisons. Six comparisons were tested by 2 to 10 trials, the others by small single-centre trials only. Twelve studies evaluated non-surgical treatments, 10 compared surgical with non-surgical treatments, 23 compared two methods of surgery, and two tested timing of mobilisation after surgery. Most trials were at high risk of bias, due mainly to lack of blinding. We summarise the findings for four key comparisons below. Early (usually one week post injury) versus delayed (after three or more weeks) mobilisation for non-surgically-treated fractures Five trials (350 participants) made this comparison; however, the available data are very limited. Due to very low-certainty evidence from single trials, we are uncertain of the findings of better shoulder function at one year in the early mobilisation group, or the findings of little or no between-group difference in function at 3 or 24 months. Likewise, there is very low-certainty evidence of no important between-group difference in quality of life at one year. There was one reported death and five serious shoulder complications (1.9% of 259 participants), spread between the two groups, that would have required substantive treatment. Surgical versus non-surgical treatment Ten trials (717 participants) evaluated surgical intervention for displaced fractures (66% were three- or four-part fractures). There is high-certainty evidence of no clinically important difference between surgical and non-surgical treatment in patient-reported shoulder function at one year (standardised mean difference (SMD) 0.10, 95% confidence interval (CI) -0.07 to 0.27; 7 studies, 552 participants) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 5 studies, 423 participants). There is moderate-certainty evidence of no clinically important between-group difference in patient-reported shoulder function at six months (SMD 0.17, 95% CI -0.04 to 0.38; 3 studies, 347 participants). There is high-certainty evidence of no clinically important between-group difference in quality of life at one year (EQ-5D (0: dead to 1: best quality): mean difference (MD) 0.01, 95% CI -0.02 to 0.04; 6 studies, 502 participants). There is low-certainty evidence of little between-group difference in mortality: one of the 31 deaths was explicitly linked with surgery (risk ratio (RR) 1.35, 95% CI 0.70 to 2.62; 8 studies, 646 participants). There is low-certainty evidence of a higher risk of additional surgery in the surgery group (RR 2.06, 95% CI 1.21 to 3.51; 9 studies, 667 participants). Based on an illustrative risk of 35 subsequent operations per 1000 non-surgically-treated patients, this indicates an extra 38 subsequent operations per 1000 surgically-treated patients (95% CI 8 to 94 more). Although there was low-certainty evidence of a higher overall risk of adverse events after surgery, the 95% CI also includes a slightly increased risk of adverse events after non-surgical treatment (RR 1.46, 95% CI 0.92 to 2.31; 3 studies, 391 participants). Open reduction and internal fixation with a locking plate versus a locking intramedullary nail Four trials (270 participants) evaluated surgical intervention for displaced fractures (63% were two-part fractures). There is low-certainty evidence of no clinically important between-group difference in shoulder function at one year (SMD 0.15, 95% CI -0.12 to 0.41; 4 studies, 227 participants), six months (Disability of the Arm, Shoulder, and Hand questionnaire (0 to 100: worst disability): MD -0.39, 95% CI -4.14 to 3.36; 3 studies, 174 participants), or two years (American Shoulder and Elbow Surgeons score (ASES) (0 to 100: best outcome): MD 3.06, 95% CI -0.05 to 6.17; 2 studies, 101 participants). There is very low-certainty evidence of no between-group difference in quality of life (1 study), and of little difference in adverse events (4 studies, 250 participants) and additional surgery (3 studies, 193 participants). Reverse total shoulder arthroplasty (RTSA) versus hemiarthroplasty There is very low-certainty evidence from two trials (161 participants with either three- or four-part fractures) of no or minimal between-group differences in self-reported shoulder function at one year (1 study) or at two to three years' follow-up (2 studies); or in quality of life at one year or at two or more years' follow-up (1 study). Function at six months was not reported. Of 10 deaths reported by one trial (99 participants), one appeared to be surgery-related. There is very low-certainty evidence of a lower risk of complications after RTSA (2 studies). Ten people (6.2% of 161 participants) had a reoperation; all eight cases in the hemiarthroplasty group received a RTSA (very low-certainty evidence).
AUTHORS' CONCLUSIONS
There is high- or moderate-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures. It may increase the need for subsequent surgery. The evidence is absent or insufficient for people aged under 60 years, high-energy trauma, two-part tuberosity fractures or less common fractures, such as fracture dislocations and articular surface fractures. There is insufficient evidence from randomised trials to inform the choices between different non-surgical, surgical or rehabilitation interventions for these fractures.
Topics: Adult; Aged; Arthroplasty, Replacement, Shoulder; Female; Fracture Fixation; Humans; Male; Quality of Life; Randomized Controlled Trials as Topic; Shoulder Fractures
PubMed: 35727196
DOI: 10.1002/14651858.CD000434.pub5 -
Archives of Orthopaedic and Trauma... Aug 2023Humeral shaft fractures can be treated non-operatively or operatively. The optimal management is subject to debate. The aim was to compare non-operative and operative... (Review)
Review
INTRODUCTION
Humeral shaft fractures can be treated non-operatively or operatively. The optimal management is subject to debate. The aim was to compare non-operative and operative treatment of a humeral shaft fracture in terms of fracture healing, complications, and functional outcome.
METHODS
Databases of Embase, Medline ALL, Web-of-Science Core Collection, and the Cochrane Central Register of Controlled Trials (CENTRAL) were systematically searched for publications reporting clinical and functional outcomes of humeral shaft fractures after non-operative treatment with a functional brace or operative treatment by intramedullary nailing (IMN; antegrade or retrograde) or plate osteosynthesis (open plating or minimally invasive). A pooled analysis of the results was performed using MedCalc.
RESULTS
A total of 173 studies, describing 11,868 patients, were included. The fracture healing rate for the non-operative group was 89% (95% confidence interval (CI) 84-92%), 94% (95% CI 92-95%) for the IMN group and 96% (95% CI 95-97%) for the plating group. The rate of secondary radial nerve palsies was 1% in patients treated non-operatively, 3% in the IMN, and 6% in the plating group. Intraoperative complications and implant failures occurred more frequently in the IMN group than in the plating group. The DASH score was the lowest (7/100; 95% CI 1-13) in the minimally invasive plate osteosynthesis group. The Constant-Murley and UCLA shoulder score were the highest [93/100 (95% CI 92-95) and 33/35 (95% CI 32-33), respectively] in the plating group.
CONCLUSION
This study suggests that even though all treatment modalities result in satisfactory outcomes, operative treatment is associated with the most favorable results. Disregarding secondary radial nerve palsy, specifically plate osteosynthesis seems to result in the highest fracture healing rates, least complications, and best functional outcomes compared with the other treatment modalities.
Topics: Humans; Fracture Fixation, Internal; Fracture Fixation, Intramedullary; Humeral Fractures; Fracture Healing; Bone Plates; Radial Neuropathy; Humerus; Treatment Outcome
PubMed: 37093269
DOI: 10.1007/s00402-023-04836-8 -
The American Journal of Occupational... 2017People with musculoskeletal disorders of the shoulder commonly experience pain, decreased strength, and restricted range of motion (ROM) that limit participation in... (Review)
Review
People with musculoskeletal disorders of the shoulder commonly experience pain, decreased strength, and restricted range of motion (ROM) that limit participation in meaningful occupational activities. The purpose of this systematic review was to evaluate the current evidence for interventions within the occupational therapy scope of practice that address pain reduction and increase participation in functional activities. Seventy-six studies were reviewed for this study-67 of Level I evidence, 7 of Level II evidence, and 2 of Level III evidence. Strong evidence was found that ROM, strengthening exercises, and joint mobilizations can improve function and decrease pain. The evidence to support physical modalities is moderate to mixed, depending on the shoulder disorder. Occupational therapy practitioners can use this evidence to guide daily clinical decision making.
Topics: Bursitis; Exercise Therapy; Humans; Humeral Fractures; Muscle Stretching Exercises; Musculoskeletal Diseases; Neck Pain; Occupational Therapy; Range of Motion, Articular; Rotator Cuff Injuries; Shoulder Impingement Syndrome; Shoulder Pain; Treatment Outcome
PubMed: 28027039
DOI: 10.5014/ajot.2017.023127 -
Ultrasound in Obstetrics & Gynecology :... Sep 2019To determine accurate estimates of risks of maternal and neonatal complications in pregnancies with fetal macrosomia by performing a systematic review of the literature... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To determine accurate estimates of risks of maternal and neonatal complications in pregnancies with fetal macrosomia by performing a systematic review of the literature and meta-analysis.
METHODS
A search of MEDLINE, EMBASE, CINAHL and The Cochrane Library was performed to identify relevant studies reporting on maternal and/or neonatal complications in pregnancies with macrosomia having a birth weight (BW) > 4000 g and/or those with birth weight > 4500 g. Prospective and retrospective cohort and population-based studies that provided data regarding both cases and controls were included. Maternal outcomes assessed were emergency Cesarean section (CS), postpartum hemorrhage (PPH) and obstetric anal sphincter injury (OASIS). Neonatal outcomes assessed were shoulder dystocia, obstetric brachial plexus injury (OBPI) and birth fractures. Meta-analysis using a random-effects model was used to estimate weighted pooled estimates of summary statistics (odds ratio (OR) and 95% CI) for each complication, according to birth weight. Heterogeneity between studies was estimated using Cochran's Q, I statistic and funnel plots.
RESULTS
Seventeen studies reporting data on maternal and/or neonatal complications in pregnancy with macrosomia were included. In pregnancies with macrosomia having a BW > 4000 g, there was an increased risk of the maternal complications: emergency CS, PPH and OASIS, which had OR (95% CI) of 1.98 (1.80-2.18), 2.05 (1.90-2.22) and 1.91 (1.56-2.33), respectively. The corresponding values for pregnancies with BW > 4500 g were: 2.55 (2.33-2.78), 3.15 (2.14-4.63) and 2.56 (1.97-3.32). Similarly, in pregnancies with a BW > 4000 g, there was an increased risk of the neonatal complications: shoulder dystocia, OBPI and birth fractures, which had OR (95% CI) of 9.54 (6.76-13.46), 11.03 (7.06-17.23) and 6.43 (3.67-11.28), respectively. The corresponding values for pregnancies with a BW > 4500 g were: 15.64 (11.31-21.64), 19.87 (12.19-32.40) and 8.16 (2.75-24.23).
CONCLUSION
Macrosomia is associated with serious maternal and neonatal adverse outcomes. This study provides accurate estimates of these risks, which can be used for decisions on pregnancy management. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
Topics: Adult; Cesarean Section; Dystocia; Female; Fetal Macrosomia; Humans; Infant, Newborn; Infant, Newborn, Diseases; Postpartum Hemorrhage; Pregnancy; Pregnancy Complications; Retrospective Studies
PubMed: 30938004
DOI: 10.1002/uog.20279 -
Journal of Shoulder and Elbow Surgery Nov 2022Since the introduction of the Grammont-style reverse total shoulder arthroplasty, the humeral stem design has been modified with improved clinical outcomes. Two distinct... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Since the introduction of the Grammont-style reverse total shoulder arthroplasty, the humeral stem design has been modified with improved clinical outcomes. Two distinct humeral designs have been used extensively: the inlay design, in which the humeral tray is seated within the metaphysis, and the onlay design, in which the humeral tray sits on the metaphysis at the level of the humeral neck cut. The purpose of this systematic review was to determine whether there are differences in clinical outcomes and complication rates between these designs.
METHODS
The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were used to perform this systematic review. A search of MEDLINE, PubMed, and Embase was performed to identify all studies comparing the clinical results of both humeral designs. Primary outcomes included patient-reported outcome measures, shoulder range of motion, and incidence of complications.
RESULTS
From the 156 identified publications, 12 studies were included in the final review. A total of 1447 patients were included, with a minimum follow-up period of 12 months. At final follow-up, both implants demonstrated significant improvements in comparison to preoperative baseline. On comparison of the inlay vs. onlay groups, the American Shoulder and Elbow Surgeons score was higher in the inlay group (mean difference, 2.53 [95% confidence interval, 0.27-4.78]; P = .03). Postoperative motion, even if statistically greater in the onlay group (differences of 5° in forward flexion [P < .001], 3° in abduction [P = .003], and 4° in external rotation [P < .001]), was not clinically different. On comparison of complications, the inlay group showed more instances of scapular notching (93 of 322 patients vs. 70 of 415 patients; odds ratio, 0.35; P < .001) but fewer scapular spine fractures (26 of 727 patients vs. 21 of 559 patients, P = .09).
DISCUSSION
Inlay and onlay humeral tray designs in reverse total shoulder arthroplasty demonstrate similar clinical improvements postoperatively. Onlay implants have a low rate of scapular notching but a higher rate of scapular spine fracture. Understanding the strengths and weaknesses of the 2 humeral tray designs is important to provide surgeons with options to tailor surgical plans for high-risk patients.
Topics: Humans; Arthroplasty, Replacement, Shoulder; Shoulder Joint; Humerus; Scapula; Range of Motion, Articular
PubMed: 35671928
DOI: 10.1016/j.jse.2022.05.002 -
Knee Surgery, Sports Traumatology,... Jun 2022The extent of shoulder instability and the indication for surgery may be determined by the prevalence or size of associated lesions. However, a varying prevalence is... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The extent of shoulder instability and the indication for surgery may be determined by the prevalence or size of associated lesions. However, a varying prevalence is reported and the actual values are therefore unclear. In addition, it is unclear whether these lesions are present after the first dislocation and whether or not these lesions increase in size after recurrence. The aim of this systematic review was (1) to determine the prevalence of lesions associated with traumatic anterior shoulder dislocations, (2) to determine if the prevalence is higher following recurrent dislocations compared to first-time dislocations and (3) to determine if the prevalence is higher following complete dislocations compared to subluxations.
METHODS
PubMed, EMBASE, Cochrane and Web of Science were searched. Studies examining shoulders after traumatic anterior dislocations during arthroscopy or with MRI/MRA or CT published after 1999 were included. A total of 22 studies (1920 shoulders) were included.
RESULTS
The proportion of Hill-Sachs and Bankart lesions was higher in recurrent dislocations (85%; 66%) compared to first-time dislocations (71%; 59%) and this was statistically significant (P < 0.01; P = 0.05). No significant difference between recurrent and first-time dislocations was observed for SLAP lesions, rotator-cuff tears, bony Bankart lesions, HAGL lesions and ALPSA lesions. The proportion of Hill-Sachs lesions was significantly higher in complete dislocations (82%) compared to subluxations (54%; P < 0.01).
CONCLUSION
Higher proportions of Hill-Sachs and Bankart were observed in recurrent dislocations compared to first-time dislocations. No difference was observed for bony Bankart, HAGL, SLAP, rotator-cuff tear and ALPSA. Especially when a Hill-Sachs or Bankart is present after first-time dislocation, early surgical stabilization may need to be considered as other lesions may not be expected after recurrence and to limit lesion growth. However, results should be interpreted with caution due to substantial heterogeneity and large variance.
LEVEL OF EVIDENCE
IV.
Topics: Arthroscopy; Bankart Lesions; Humans; Joint Dislocations; Joint Instability; Prevalence; Recurrence; Retrospective Studies; Rotator Cuff Injuries; Shoulder Dislocation; Shoulder Joint
PubMed: 34988633
DOI: 10.1007/s00167-021-06847-7 -
The Cochrane Database of Systematic... Nov 2015Fracture of the proximal humerus, often termed shoulder fracture, is a common injury in older people. The management of these fractures varies widely. This is an update... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Fracture of the proximal humerus, often termed shoulder fracture, is a common injury in older people. The management of these fractures varies widely. This is an update of a Cochrane Review first published in 2001 and last updated in 2012.
OBJECTIVES
To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults.
SEARCH METHODS
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and other databases, conference proceedings and bibliographies of trial reports. The full search ended in November 2014.
SELECTION CRITERIA
We considered all randomised controlled trials (RCTs) and quasi-randomised controlled trials pertinent to the management of proximal humeral fractures in adults.
DATA COLLECTION AND ANALYSIS
Both review authors performed independent study selection, risk of bias assessment and data extraction. Only limited meta-analysis was performed.
MAIN RESULTS
We included 31 heterogeneous RCTs (1941 participants). Most of the 18 separate treatment comparisons were tested by small single-centre trials. The main exception was the surgical versus non-surgical treatment comparison tested by eight trials. Except for a large multicentre trial, bias in these trials could not be ruled out. The quality of the evidence was either low or very low for all comparisons except the largest comparison.Nine trials evaluated non-surgical treatment in mainly minimally displaced fractures. Four trials compared early (usually one week) versus delayed (three or four weeks) mobilisation after fracture but only limited pooling was possible and most of the data were from one trial (86 participants). This found some evidence that early mobilisation resulted in better recovery and less pain in people with mainly minimally displaced fractures. There was evidence of little difference between the two groups in shoulder complications (2/127 early mobilisation versus 3/132 delayed mobilisation; 4 trials) and fracture displacement and non-union (2/52 versus 1/54; 2 trials).One quasi-randomised trial (28 participants) found the Gilchrist-type sling was generally more comfortable than the Desault-type sling (body bandage). One trial (48 participants) testing pulsed electromagnetic high-frequency energy provided no evidence. Two trials (62 participants) provided evidence indicating little difference in outcome between instruction for home exercises versus supervised physiotherapy. One trial (48 participants) reported, without presentable data, that home exercise alone gave better early and comparable long-term results than supervised exercise in a swimming pool plus home exercise.Eight trials, involving 567 older participants, evaluated surgical intervention for displaced fractures. There was high quality evidence of no clinically important difference in patient-reported shoulder and upper-limb function at one- or two-year follow-up between surgical (primarily locking plate fixation or hemiarthroplasty) and non-surgical treatment (sling immobilisation) for the majority of displaced proximal humeral fractures; and moderate quality evidence of no clinically important difference between the two groups in quality of life at two years (and at interim follow-ups at six and 12 months). There was moderate quality evidence of little difference between groups in mortality in the surgery group (17/248 versus 12/248; risk ratio (RR) 1.40 favouring non-surgical treatment, 95% confidence interval (CI) 0.69 to 2.83; P = 0.35; 6 trials); only one death was explicitly linked with the treatment. There was moderate quality evidence of a higher risk of additional surgery in the surgery group (34/262 versus 16/261; RR 2.06, 95% CI 1.18 to 3.60; P = 0.01; 7 trials). Although there was moderate evidence of a higher risk of adverse events after surgery, the 95% confidence intervals for adverse events also included the potential for a greater risk of adverse events after non-surgical treatment.Different methods of surgical management were tested in 12 trials. One trial (57 participants) comparing two types of locking plate versus a locking nail for treating two-part surgical neck fractures found some evidence of slightly better function after plate fixation but also of a higher rate of surgically-related complications. One trial (61 participants) comparing a locking plate versus minimally invasive fixation with distally inserted intramedullary K-wires found little difference between the two implants at two years. Compared with hemiarthroplasty, one trial (32 participants) found similar results with locking plate fixation in function and re-operation rates, whereas another trial (30 participants) reported all five re-operations occurred in the tension-band fixation group. One trial (62 participants) found better patient-rated (Quick DASH) and composite shoulder function scores at a minimum of two years follow-up and a lower incidence of re-operation and complications after reverse shoulder arthroplasty (RSA) compared with hemiarthroplasty.No important between-group differences were found in one trial (120 participants) comparing the deltoid-split approach versus deltopectoral approach for non-contact bridging plate fixation, and two trials (180 participants) comparing 'polyaxial' and 'monaxial' screws in locking plate fixation. One trial (68 participants) produced some preliminary evidence that tended to support the use of medial support locking screws in locking plate fixation. One trial (54 participants) found fewer adverse events, including re-operations, for the newer of two types of intramedullary nail. One trial (35 participants) found better functional results for one of two types of hemiarthroplasty. One trial (45 participants) found no important effects of tenodesis of the long head of the biceps for people undergoing hemiarthroplasty.Very limited evidence suggested similar outcomes from early versus later mobilisation after either surgical fixation (one trial: 64 participants) or hemiarthroplasty (one trial: 49 participants).
AUTHORS' CONCLUSIONS
There is high or moderate quality evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures involving the humeral neck and is likely to result in a greater need for subsequent surgery. The evidence does not cover the treatment of two-part tuberosity fractures, fractures in young people, high energy trauma, nor the less common fractures such as fracture dislocations and head splitting fractures.There is insufficient evidence from RCTs to inform the choices between different non-surgical, surgical, or rehabilitation interventions for these fractures.
Topics: Adult; Bandages; Early Ambulation; Fracture Fixation; Humans; Immobilization; Physical Therapy Modalities; Randomized Controlled Trials as Topic; Self Care; Shoulder Fractures; Treatment Outcome
PubMed: 26560014
DOI: 10.1002/14651858.CD000434.pub4 -
British Journal of Sports Medicine Jul 2015Recurrent instability following a first-time anterior traumatic shoulder dislocation may exceed 26%. We systematically reviewed risk factors which predispose this... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Recurrent instability following a first-time anterior traumatic shoulder dislocation may exceed 26%. We systematically reviewed risk factors which predispose this population to events of recurrence.
METHODS
A systematic review of studies published before 1 July 2014. Risk factors which predispose recurrence following a first-time traumatic anterior shoulder dislocation were documented and rates of recurrence were compared. Pooled ORs were analysed using random-effects meta-analysis.
RESULTS
Ten studies comprising 1324 participants met the criteria for inclusion. Recurrent instability following a first-time traumatic anterior shoulder dislocation was 39%. Increased risk of recurrent instability was reported in people aged 40 years and under (OR=13.46), in men (OR=3.18) and in people with hyperlaxity (OR=2.68). Decreased risk of recurrent instability was reported in people with a greater tuberosity fracture (OR=0.13). The rate of recurrent instability decreased as time from the initial dislocation increased. Other factors such as a bony Bankart lesion, nerve palsy and occupation influenced rates of recurrent instability.
CONCLUSIONS
Sex, age at initial dislocation, time from initial dislocation, hyperlaxity and greater tuberosity fractures were key risk factors in at least two good quality cohort studies resulting in strong evidence as concluded in the GRADE criteria. Although bony Bankart lesions, Hill Sachs lesions, occupation, physiotherapy treatment and nerve palsy were risk factors for recurrent instability, the evidence was weak using the GRADE criteria-these findings relied on poorer quality studies or were inconsistent among studies.
Topics: Adolescent; Adult; Age Factors; Aged; Aged, 80 and over; Disease Susceptibility; Female; Humans; Joint Instability; Male; Middle Aged; Recurrence; Risk Factors; Sex Factors; Shoulder Dislocation; Young Adult
PubMed: 25900943
DOI: 10.1136/bjsports-2014-094342 -
Archives of Physical Medicine and... Jun 2024To compare single and multiple physiotherapy sessions to improve pain, function, and quality of life (QoL) in patients with musculoskeletal disorders (MSKDs). (Meta-Analysis)
Meta-Analysis
One and Done? The Effectiveness of a Single Session of Physiotherapy Compared With Multiple Sessions to Reduce Pain and Improve Function and Quality of Life in Patients With a Musculoskeletal Disorder: A Systematic Review With Meta-analyses.
OBJECTIVE
To compare single and multiple physiotherapy sessions to improve pain, function, and quality of life (QoL) in patients with musculoskeletal disorders (MSKDs).
DATA SOURCES
AMED, Cinahl, SportsDiscus, Medline, Cochrane Register of Clinical Trials, Physiotherapy Evidence Database, and reference lists.
STUDY SELECTION
Randomized controlled trials (RCTs) comparing single and multiple physiotherapy sessions for MSKDs.
DATA EXTRACTION
Two reviewers extracted data and assessed risk of bias and certainty of evidence using Cochrane Risk of Bias tool 2.0 and Grading of Recommendation Assessment, Development, and Evaluation.
DATA SYNTHESIS
Six RCTs (n=2090) were included (conditions studied: osteoporotic vertebral fracture, neck, knee, and shoulder pain). Meta-analyses with low-certainty evidence showed a significant pain improvement at 6 months in favor of multiple sessions compared with single session interventions (3 RCTs; n=1035; standardized mean difference [SMD]: 0.29; 95% CI: 0.05 to 0.53; P=.02) but this significant difference in pain improvement was not observed at 3 months (4 RCTs; n=1312; SMD: 0.39; 95% CI: -0.11 to 0.89; P=.13) and at 12 months (4 RCTs; n=1266; SMD: -0.05; 95% CI: -0.49 to 0.39; P=.82). Meta-analyses with low-certainty evidence showed no significant differences in function at 3 (4 RCTs; n=1583; SMD: 0.05; 95% CI: -0.11 to 0.21; P=.56), 6 (4 RCTs; n=1538; SMD: 0.06; 95% CI: -0.12 to 0.23; P=.53) and 12 months (4 RCTs; n=1528; SMD: 0.08; 95% CI: -0.08 to 0.25; P=.30) and QoL at 3 (4 RCTs; n=1779; SMD: 0.08; 95% CI: -0.02 to 0.17; P=.12), 6 (3 RCTs; n=1206; SMD: 0.03; 95% CI: -0.08 to 0.14; P=.59), and 12 months (4 RCTs; n=1729; SMD: -0.03; 95% CI: -0.12 to 0.07; P=.58).
CONCLUSIONS
Low certainty meta-analyses found no clinically significant differences in pain, function, and QoL between single and multiple physiotherapy sessions for MSKD management for the conditions studied. Future research should compare the cost-effectiveness of those different models of care.
Topics: Humans; Musculoskeletal Diseases; Pain Management; Physical Therapy Modalities; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 37805175
DOI: 10.1016/j.apmr.2023.09.017 -
The Cochrane Database of Systematic... Jun 2017Gestational diabetes mellitus (GDM) is associated with both short- and long-term complications for the mother and her baby. Exercise interventions may be useful in... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Gestational diabetes mellitus (GDM) is associated with both short- and long-term complications for the mother and her baby. Exercise interventions may be useful in helping with glycaemic control and improve maternal and infant outcomes.The original review on Exercise for diabetic pregnant women has been split into two new review titles reflecting the role of exercise for pregnant women with gestational diabetes and for pregnant women with pre-existing diabetes. Exercise for pregnant women with gestational diabetes for improving maternal and fetal outcomes (this review) Exercise for pregnant women with pre-existing diabetes for improving maternal and fetal outcomes OBJECTIVES: To evaluate the effects of exercise interventions for improving maternal and fetal outcomes in women with GDM.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 August 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (18th August 2016), and reference lists of retrieved studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) comparing an exercise intervention with standard care or another intervention in pregnant women diagnosed with gestational diabetes. Quasi-randomised and cross-over studies, and studies including women with pre-existing type 1 or type 2 diabetes were not eligible for inclusion.
DATA COLLECTION AND ANALYSIS
All selection of studies, assessment of trial quality and data extraction was conducted independently by two review authors. Data were checked for accuracy.
MAIN RESULTS
We included 11 randomised trials, involving 638 women. The overall risk of bias was judged to be unclear due to lack of methodological detail in the included studies.For the mother, there was no clear evidence of a difference between women in the exercise group and those in the control group for the risk of pre-eclampsia as the measure of hypertensive disorders of pregnancy (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.01 to 7.09; two RCTs, 48 women; low-quality evidence), birth by caesarean section (RR 0.86, 95% CI 0.63 to 1.16; five RCTs, 316 women; I = 0%; moderate-quality evidence), the risk of induction of labour (RR 1.38, 95% CI 0.71 to 2.68; one RCT, 40 women; low-quality evidence) or maternal body mass index at follow-up (postnatal weight retention or return to pre-pregnancy weight) (mean difference (MD) 0.11 kg/m, 95% CI -1.04 to 1.26; three RCTs, 254 women; I = 0%; high-quality evidence). Development of type 2 diabetes, perineal trauma/tearing and postnatal depression were not reported as outcomes in the included studies.For the infant/child/adult, a single small (n = 19) trial reported no perinatal mortality (stillbirth and neonatal mortality) events in either the exercise intervention or control group (low-quality evidence). There was no clear evidence of a difference between groups for a mortality and morbidity composite (variously defined by trials, e.g. perinatal or infant death, shoulder dystocia, bone fracture or nerve palsy) (RR 0.56, 95% CI 0.12 to 2.61; two RCTs, 169 infants; I = 0%; moderate-quality evidence) or neonatal hypoglycaemia (RR 2.00, 95% CI 0.20 to 20.04; one RCT, 34 infants; low-quality evidence). None of the included trials pre-specified large-for-gestational age, adiposity (neonatal/infant, childhood or adulthood), diabetes (childhood or adulthood) or neurosensory disability (neonatal/infant) as trial outcomes.Other maternal outcomes of interest: exercise interventions were associated with both reduced fasting blood glucose concentrations (average standardised mean difference (SMD) -0.59, 95% CI -1.07 to -0.11; four RCTs, 363 women; I = 73%; T = 0.19) and a reduced postprandial blood glucose concentration compared with control interventions (average SMD -0.85, 95% CI -1.15 to -0.55; three RCTs, 344 women; I = 34%; T = 0.03).
AUTHORS' CONCLUSIONS
Short- and long-term outcomes of interest for this review were poorly reported. Current evidence is confounded by the large variety of exercise interventions. There was insufficient high-quality evidence to be able to determine any differences between exercise and control groups for our outcomes of interest. For the woman, both fasting and postprandial blood glucose concentrations were reduced compared with the control groups. There are currently insufficient data for us to determine if there are also benefits for the infant. The quality of the evidence in this review ranged from high to low quality and the main reason for downgrading was for risk of bias and imprecision (wide CIs, low event rates and small sample size). Development of type 2 diabetes, perineal trauma/tearing, postnatal depression, large-for-gestational age, adiposity (neonate/infant, childhood or adulthood), diabetes (childhood or adulthood) or neurosensory disability (neonate/infant) were not reported as outcomes in the included studies.Further research is required comparing different types of exercise interventions with control groups or with another exercise intervention that reports on both the short- and long-term outcomes (for both the mother and infant/child) as listed in this review.
Topics: Adult; Body Mass Index; Cesarean Section; Diabetes, Gestational; Dystocia; Exercise Therapy; Female; Humans; Hypoglycemia; Infant; Infant, Newborn; Labor, Induced; Perinatal Mortality; Pre-Eclampsia; Pregnancy; Randomized Controlled Trials as Topic
PubMed: 28639706
DOI: 10.1002/14651858.CD012202.pub2