### Systematic Review Scenario

A 58 year old male presented with right shoulder pain developing over the past two weeks, with no history of trauma. Movements were generally painful and restricted, in particular abduction. X-ray was normal. We formulate the question, is corticosteroid injection or physiotherapy more effective in patients with rotator cuff tendinitis?

Searching terms and evidence source: Cochrane Library was searched for “shoulder pain” (Title only) giving a Cochrane review and 39 CCTR “hits”.

• Is the evidence from this study valid?
• If valid, is this evidence important?
• If valid and important, can you apply this evidence in caring for your patient?

### Completed Systematic Reviews Worksheet for Evidence-Based General Practice

#### Citation

Green S, Buchbinder R, Glazier R, Forbes A. Interventions for shoulder pain (Cochrane Review). In: The Cochrane Library, Issue 1, 1999. Oxford: Update Software.

#### Are the results of this systematic review of therapy valid?

Is it a systematic review of randomised trials of the treatment you’re interested in?
Yes
Does it include a methods section that describes finding and including all the relevant trials?
Yes, an extensive computer and hand-search was used.
Does it include a methods section that describes assessing their individual validity?
Methodological quality was assessed by two reviewers blinded to study results.
Were the results consistent from study to study?
28 included studies only a few had comparable populations and methods.

#### Are the valid results of this systematic review important?

Translating odds ratios to NNTs. The numbers in the body of the table are the NNTs for the corresponding odds ratios at that particular patient’s expected event rate (PEER).
Odds Ratios
0.9 0.85 0.8 0.75 0.7 0.65 0.6 0.55 0.5
Patient’s Expected Event Rate (PEER) 0.05 2091 139 104 83 69 59 52 46 412
0.10 110 73 54 43 36 31 27 24 21
0.20 61 40 30 24 20 17 14 13 11
0.30 46 30 22 18 14 12 10 9 8
0.40 40 26 19 15 12 10 9 8 7
0.503 38 25 18 14 11 9 8 7 6
0.70 44 28 20 16 13 10 9 7 6
0.90 1014 64 46 34 27 22 18 15 125

#### Can you apply this valid, important evidence from a systematic review in caring for your patient?

##### Do these results apply to your patient?
Is your patient so different from those in the systematic review that its results can’t help you?
No
How great would the potential benefit of therapy actually be for your individual patient?
The natural history is one of spontaneous remission, but in months to years.
1. Method I: In the table on page 1, find the intersection of the closest odds ratio from the overview and the CER that is closest to your patient’s expected event rate if they received the control treatment (PEER):
N/A
2. Method II: To calculate the NNT for any OR and PEER:
$$mathit{NNT} = frac{1-[mathit{PEER} times (1-mathit{OR})]}{(1-mathit{PEER})times mathit{PEER} times (1-mathit{OR})}\\ text{N/A}$$
##### Are your patient’s values and preferences satisfied by the regimen and its consequences?
Do your patient and you have a clear assessment of their values and preferences?
Yes. They would prefer relief but not at the cost of risky or painful treatment.
Are they met by this regimen and its consequences?
Yes.
##### Should you believe apparent qualitative differences in the efficacy of therapy in some subgroups of patients?

Only if you can say “yes” to all of the following:

• Do they really make biologic and clinical sense?
• Is the qualitative difference both clinically (beneficial for some but useless or harmful for others) and statistically significant?
• Was this difference hypothesised before the study began (rather than the product of dredging the data), and has it been confirmed in other, independent studies?
• Was this one of just a few subgroup analyses carried out in this study?

### Rotator cuff tendonitis – Subacromial corticosteroids decreases pain

#### Clinical Bottom Line

Subacromial injection of corticosteroids in patients with rotator cuff tendonitis has modest benefits on pain and range of motion.

#### Citation

Green S, Buchbinder R, Glazier R, Forbes A. Interventions for shoulder pain (Cochrane Review). In: The Cochrane Library, Issue 1, 1999. Oxford: Update Software.

#### Clinical Question

Are corticosteroid injections or physiotherapy effective in rotator cuff tendinitis?

#### Search Terms

“shoulder pain” in title – Cochrane Library

#### The Study

This review used an extenstive search strategy to identify 58 studies of treatment of painful shoulder; 27 trials were excluded because of non-randomization or lack of blinding. The 31 included studies had a variety of interventions including: NSAIDs (17 trials), intra-articular and subacromial corticosteroids (10 trials), physiotherapy (5 trials), and oral glucocorticoids (2 trials). Most measured pain and range of movement as outcomes. On a quality scale of 0 to 40, the mean trial quality was 16.8, with the highest being 22.

#### The Evidence

Data from two trials was pooled to determine the efficacy of subacromial steroid injection versus placebo in rotator cuff tendinitis. The Weighted Mean Difference suggested injection was superior to placebo in improving range of abduction (WMD = 35; 95%CI 14 to 55), and in pain (on a visual analogue scale).

The studies were generally small, of variable and low quality, and used very different populations and methods. However, there appears to be a consistent trend in favour of anti-inflammatory treatment, in particular, subacromial corticosteroids.

Paul Glasziou

#### References

1. The relative risk reduction (RRR) here is 10%
2. The RRR here is 49%
3. For any OR, NNT is lowest when PEER = .50
4. The RRR here is 1%
5. The RRR here is 9%