Management of the Unilateral Shoulder Impingement SyndromeTO THE EDITOR: On the surface, Rhon and colleagues' thoughtful study (1) shows the effectiveness of subacromial corticosteroid injection and manual physical therapy (MPT) to treat the shoulder impingement syndrome (SIS). However, several factors complicate the comparison of MPT with medical intervention and perhaps limit this study's otherwise valuable contribution.First, the manual therapy approach used was welldescribed in Rhon and colleagues' study (1) and elsewhere (2). However, physical therapists in clinical practice typically assess the presence and quality of symptoms in relation to patient movement and position, not according to a pathoanatomical diagnosis, such as SIS. Therefore, including MPT as a treatment for SIS may be misleading. The authors should have emphasized the idea that MPT treats the mechanical stresses that may lead to SIS, whereas corticosteroid injection more directly affects the structures that have been injured.Second, manual physical therapists continually reassess and adjust treatment on the basis of the patient's symptomatic changes structured as a test-retest model (establish a baseline, do an intervention, and then retest to look for change from the baseline). This model has been validated (3) and is the common thread linking many assessment approaches used by all types of physical therapists. This model differs from a physician's typical assessment and treatment in that therapists spend more time (generally 2 to 3 sessions weekly for at least 4 weeks) observing patients move and evaluating their response to various noninvasive interventions.Third, this study may not have sufficiently emphasized the patient education process. Many musculoskeletal conditions involving the shoulders have high recurrence rates (4), particularly when the mechanism of injury is progressive and is thought to result from repetitive overuse of the injured area. In these frequent cases, resolution and recurrence of symptoms may simply be part of the natural history of the condition; short-term pain control and improved functionality would not be the ultimate goal of intervention. Physical therapists educate their patients to become their own "selfassessors" and learn how and when to use appropriate self-treatment techniques as developed through the assessment approach used when deciding on suitable manual techniques.Finally, corticosteroid injection and MPT often work in synergy: The former decreases inflammation, and the latter decreases the mechanical stress that may have caused the symptoms in the first place. Including a third group that received both interventions might have allowed for a more clinically relevant comparison.
Background-Atrial fibrillation is an important cause of cardioembolic stroke. Oral anticoagulants (OAC) reduce stroke risk but increase the risk of serious bleeding. Left atrial appendage (LAA) procedures have been developed to isolate the LAA from circulating blood flow, as an alternative to OAC. We conducted a systematic review of the benefits and harms of surgical and percutaneous LAA exclusion procedures. Methods and Results-We searched multiple data sources, including Ovid MEDLINE, Cochrane, and Embase, through January 7, 2015. Of 2567 citations, 20 primary studies met prespecified inclusion criteria. We abstracted data on patient characteristics, stroke, mortality, and adverse effects. We assessed study quality and graded the strength of evidence using published criteria. Trials found low-strength evidence that percutaneous LAA exclusion confers similar risks of stroke and mortality as continued OAC, but this evidence was limited to the Watchman device in patients eligible for long-term OAC. Observational studies found moderate-strength evidence of serious harms with a variety of percutaneous LAA procedures. There is low-strength evidence that surgical LAA exclusion does not add significant harm during heart surgery for another indication, but evidence on stroke reduction is insufficient. Conclusions-There is limited evidence that the Watchman device may be noninferior to long-term OAC in selected patients.Data on effectiveness of LAA exclusion devices is lacking in patients ineligible for long-term OAC. Percutaneous LAA devices are associated with high rates of procedure-related harms. Although surgical LAA exclusion during heart surgery does not seem to add incremental harm, there is insufficient evidence of benefit. (Circ Cardiovasc Qual Outcomes. 2016;9:395-405.
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