Is subacromial decompression unnecessary? There may be prerequisites.
In the BMJ (2018; 362:k2860), Paavola et al. reported a randomised, placebo surgery controlled clinical trial involving patients with shoulder impingement syndrome (SIS), and concluded that arthroscopic subacromial decompression (ASD) provided no benefit over diagnostic arthroscopy (DA)1.
Multi-centre randomised controlled trials (RCTs) are commonly considered as the highest level of medical evidence. Influenced by their findings, the orthopaedic community will propose to limit the surgical indications, and thus significantly reduce the medical burden, economic pressure and medical injuries. Because these findings will have a great influence on clinical decision-making, great care needs to be taken in using their conclusions.
In fact, their conclusions are based on an important hidden premise. Both the ASD and DA groups underwent very good postoperative rehabilitation and performed home exercises. Previously, many researchers have found that a specific exercise strategy can significantly reduce clinical symptoms and the need for surgery 2 3. In this study, the authors gave a secondary comparison (ASD versus exercise therapy) and found statistically significant differences. However, exercise therapy also improved the visual analogue scale (VAS) scores, while the P values (P = 0.023 and P = 0.008) are in fact not particularly striking. If the authors had provided the missing third comparison (DA versus exercise therapy), they may have found that there was no difference between DA and exercise therapy, and then realized that good postoperative rehabilitation and home exercises may have had a very big impact. The data presented cannot rule out whether the postoperative rehabilitation and exercise program may have caused the lack of a significant difference between the ASD and DA groups.
As a consequence, their conclusions may only apply in some developed countries, in which there is very good provision for rehabilitation and patient compliance is also good, but not for the whole world. Doctors in different countries, especially in countries where it is difficult to provide suitable rehabilitation conditions or to ensure patient compliance in the short term, should make decisions on the basis of specific national circumstances, instead of blindly following the results of studies performed under different conditions.
References:
1. Paavola M, Malmivaara A, Taimela S, et al. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial. BMJ (Clinical research ed) 2018;362:k2860. doi: 10.1136/bmj.k2860 [published Online First: 2018/07/22]
2. Hallgren HC, Holmgren T, Oberg B, et al. A specific exercise strategy reduced the need for surgery in subacromial pain patients. British journal of sports medicine 2014;48(19):1431-6. doi: 10.1136/bjsports-2013-093233 [published Online First: 2014/06/28]
3. Holmgren T, Bjornsson Hallgren H, Oberg B, et al. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. BMJ (Clinical research ed) 2012;344:e787. doi: 10.1136/bmj.e787 [published Online First: 2012/02/22]
Competing interests:
No competing interests
14 August 2018
Shi-Cong Tao
Orthopaedic surgeons
Shanghai Jiao Tong University Affiliated Sixth People’s Hospital
Rapid Response:
Is subacromial decompression unnecessary? There may be prerequisites.
In the BMJ (2018; 362:k2860), Paavola et al. reported a randomised, placebo surgery controlled clinical trial involving patients with shoulder impingement syndrome (SIS), and concluded that arthroscopic subacromial decompression (ASD) provided no benefit over diagnostic arthroscopy (DA)1.
Multi-centre randomised controlled trials (RCTs) are commonly considered as the highest level of medical evidence. Influenced by their findings, the orthopaedic community will propose to limit the surgical indications, and thus significantly reduce the medical burden, economic pressure and medical injuries. Because these findings will have a great influence on clinical decision-making, great care needs to be taken in using their conclusions.
In fact, their conclusions are based on an important hidden premise. Both the ASD and DA groups underwent very good postoperative rehabilitation and performed home exercises. Previously, many researchers have found that a specific exercise strategy can significantly reduce clinical symptoms and the need for surgery 2 3. In this study, the authors gave a secondary comparison (ASD versus exercise therapy) and found statistically significant differences. However, exercise therapy also improved the visual analogue scale (VAS) scores, while the P values (P = 0.023 and P = 0.008) are in fact not particularly striking. If the authors had provided the missing third comparison (DA versus exercise therapy), they may have found that there was no difference between DA and exercise therapy, and then realized that good postoperative rehabilitation and home exercises may have had a very big impact. The data presented cannot rule out whether the postoperative rehabilitation and exercise program may have caused the lack of a significant difference between the ASD and DA groups.
As a consequence, their conclusions may only apply in some developed countries, in which there is very good provision for rehabilitation and patient compliance is also good, but not for the whole world. Doctors in different countries, especially in countries where it is difficult to provide suitable rehabilitation conditions or to ensure patient compliance in the short term, should make decisions on the basis of specific national circumstances, instead of blindly following the results of studies performed under different conditions.
References:
1. Paavola M, Malmivaara A, Taimela S, et al. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial. BMJ (Clinical research ed) 2018;362:k2860. doi: 10.1136/bmj.k2860 [published Online First: 2018/07/22]
2. Hallgren HC, Holmgren T, Oberg B, et al. A specific exercise strategy reduced the need for surgery in subacromial pain patients. British journal of sports medicine 2014;48(19):1431-6. doi: 10.1136/bjsports-2013-093233 [published Online First: 2014/06/28]
3. Holmgren T, Bjornsson Hallgren H, Oberg B, et al. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. BMJ (Clinical research ed) 2012;344:e787. doi: 10.1136/bmj.e787 [published Online First: 2012/02/22]
Competing interests: No competing interests