1. Division of Population Health Sciences Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Diagnostic accuracy of clinical tests for subacromial impingement syndrome (SIS): a systematic review and meta analysis Marwan Alqunaee, Rose Galvin and Tom Fahey

2. Division of Population Health Sciences Outline Background and study aims Methods Results Clinical implications and discussion Limitation

3. Division of Population Health Sciences Background Shoulder pain is the third most common musculoskeletal consultation in primary care Subacromial impingement syndrome (SIS) is the most frequent cause of shoulder pain SIS is a clinical syndrome that indicates pain and pathology relating to the subacromial bursa and rotator cuff tendons within the subacromial space

5. Clinical testDescriptionEnd point sign Neers sign The examiner stabilizes the scapula and asks the patient to forward flex the arm until he reports pain or until full elevation is reached. Pain Hawkins- Kennedy test The examiner places the arm in a 90˚ of forward flexion and then gently internally rotates the arm. The end point for internal rotation is either when the patient feels pain or when the rotation of the scapula is felt or observed by the examiner. The test is positive when the patient experience pain during the maneuver. Pain Empty can test (supraspinatus) The examiner asks the patient to elevate and internally rotate the arm with thumbs pointing downwards in the scapular plane. The elbow should be fully extended. In this position the examiner applies downward pressure on the upper surface of the arm. Weakness Drop arm sign The patient fully elevates the arm and then slowly reverses the motion in the same arc. If the arm is dropped suddenly or the patient has severe pain the test is considered to be positive. Pain or weakness Lift off test The patient internally rotates the shoulder placing the hand on the ipsilateral buttock. He is then asked to lift the hand off the buttock against resistance. A tear in the subscapularis muscle produces weakness of this action. Weakness

6. Division of Population Health Sciences Aim Perform a systematic review and meta-analysis to determine the diagnostic accuracy of five common clinical tests to detect SIS

7. Division of Population Health Sciences Methods PRISMA guidelines Inclusion criteria 1)Study design: prospective or retrospective cohort or cross sectional studies 2)Patient population: patients (>16 years of age) with a painful shoulder 3)Explanatory variables: any of the five clinical tests reported in the study 4)Setting of care: inpatient and outpatient settings 5)Reference standard: arthroscopy or open surgery

8. Division of Population Health Sciences Methods Data extraction Data synthesis and analysis –Statistical software STATA version 10.1 – metandi commands –Bivariate random effects model - summary estimates of sensitivity and specificity and their corresponding 95% confidence intervals Quality assessment –Quality of Diagnostic Accuracy Tool (QUADAS)

9. Records identified through database searching (n = 1330) Additional records identified through other sources (n=8) Records after duplicates removed (n=1338) Records screened (n=1338) Records excluded after reading title/abstract (n=1307) Full-text articles assessed for eligibility (n=31) Articles included narrative review (n=16) Articles included meta- analysis (n=10) Excluded (n=15) Reference test not surgery (n=12) Index test used for different shoulder condition (n=2) No relevant patient group (n=1) The search yielded sixteen studies including 2390 patients and are carried out in orthopaedic or musculoskeletal outpatient clinics PRISMA flow diagram of the studies Results

10. Results ‘Rule out’ tests Clinical test No. of Studies No. of patients Pooled sensitivity (95% CI)Pooled Specificity (95% CI) Hawkins Kennedy test 610290.74(0.57-0.85)0.57(0.46-0.67) Neers sign 511270.78(0.68-0.87)0.58(0.47-0.68) Empty can test 66950.69(0.54-0.81)0.62(0.38-0.81) Drop arm test 512130.21(0.14-0.30)0.92(0.86-0.96) Lift off test 42670.42(0.19-0.69)0.97(0.79-1.00)

11. Results ‘Rule in’ tests Clinical test No. of Studies No. of patients Pooled sensitivity (95% CI)Pooled Specificity (95% CI) Hawkins Kennedy test 610290.74(0.57-0.85)0.57(0.46-0.67) Neers sign 511270.78(0.68-0.87)0.58(0.47-0.68) Empty can test 66950.69(0.54-0.81)0.62(0.38-0.81) Drop arm test 512130.21(0.14-0.30)0.92(0.86-0.96) Lift off test 42670.42(0.19-0.69)0.97(0.79-1.00)

12. Division of Population Health Sciences Clinical implications Lift off test provides strongest evidence to rule in SIS. Management of severity of SIS – physiotherapy or surgery Other predictors of SIS – signs and symptoms

13. Division of Population Health Sciences Discussion Five clinical tests suggestive of SIS have modest diagnostic discriminative value when assessed against the surgical reference standard The Hawkins-Kennedy, Neer’s test as well as the empty can test are more likely to ‘rule out’ SIS when the clinical test result is negative The drop-arm test and the lift-off test are more likely to ‘rule in’ SIS

14. Division of Population Health Sciences Limitations Setting of care Reference standard Severity of SIS and subjective nature of tests Methodological quality