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Practice Rapid Recommendations

Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l294 (Published 06 February 2019) Cite this as: BMJ 2019;364:l294

Linked Editorial

Subacromial decompression surgery for shoulder pain

Visual summary of recommendation

or Subacromial decompression surgery Nonoperativemanagement only Arthroscopic subacromial decompression plusnonoperative management Including guided physical therapy, exercise programmes, NSAIDs, and steroid injections Interventions compared Recommendation Population Adults with shoulderpain for more than 3 months Does not apply to patients with: Including: Traumatic shoulder pain Subacromial pain syndrome (SAPS) Rotator cuff disease (RCD) Other differential diagnoses

We recommend against subacromial decompression surgery Moredetails Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone.

Comparison of benefits and harms

Favours surgery Evidence quality Visual analogue scale (0–10) After 1 year No important difference The panel found that this difference was not important for most patients, because the intervention effects were negligible and/or very imprecise, for example confidence intervals that include both important benefit and harm Favours nonoperative management Evidence presented here shows the comparison between surgery and placebo surgery (diagnostic arthroscopy). Higher quality evidence was available for this comparison than for surgery versus nonoperative management, and the authors believe it is therefore a more useful guide to the effectiveness of surgery. Lower quality evidence on surgery versus nonoperative management is available in MAGIC app, using the link at the bottom of the graphic

No important difference Pain (Mean) High More 2.6 2.9

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Surgery has little or no effect on pain at 1 year A separate review found that the “minimally important difference” for patients would be an improvement of 1.5 on this scale 1.5 MID High GRADE score, because of: GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low

Constant score scale (0–100) No important difference Function (Mean) High More 72 69

A separate review found that the “minimally important difference” for patients would be an improvement of 8.3 on this scale 8.3 MID Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Surgery has little or no effecton function at 1 year High GRADE score, because of: GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low

No important difference EQ-5D scale (-0.59–1) Quality of life (Mean) High More 0.70 0.73

A separate review found that the “minimally important difference” for patients would be an improvement of 0.07 on this scale 0.07 MID Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Surgery has little or no effecton quality of life at 1 year High GRADE score, because of: GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low

635 Global perceived effect Moderate More Events per 1000 people No important difference 699

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Surgery probably has little or no global perceived effect at 1 year Moderate GRADE score, because of: GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low

No important difference At work Low More 859 818 Number of participants working at the time of outcome assessment

Risk of Bias No serious concerns Imprecision Very serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Surgery may have little or no effect on whether a person is working after 1 year Low GRADE score, because of: GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low
Events per 1000 people Within 30 days

6 fewer 0 Serious harms Moderate More 6

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Surgery probably slightly increases risk of serious harms Moderate GRADE score, because of: Data from a well performed registry study of mixed surgical procedures, resulting in indirectevidence for subacromial decompression Observed harms include: Deep vein thrombosis (20.0%) Pulmonary embolism (18.6%) Pneumonia (13.8%) Sepsis and serious infections (9.0%) Bleeding transfusion (8.3%) GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low
See patient decision aids
See all outcomes
Recovery time varies from months to years and may include sick leave Day surgery with general anaesthesia and/or nerve block After surgery, 2 weeks off work are typically needed Avoid heavy lifting for one to three weeks, overhead activities for 3 months The panel believes that all or almost all patients would place a high value on avoiding even minimal risk of complications and burden from surgery, if it is not helpful. Values and preferences Key practical issues Surgery Nonoperative management

©BMJ Publishing Group Limited.

Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: https://www.bmj.com/company/legal-information/

Find recommendations, evidence summaries and consultation decision aids for use in your practice
  1. Per Olav Vandvik, methods co-chair, general internist, methodologist1 2,
  2. Tuomas Lähdeoja, orthopedic surgeon3 4,
  3. Clare Ardern, physiotherapist5 6,
  4. Rachelle Buchbinder, rheumatologist, methodologist7,
  5. Jaydeep Moro, orthopaedic surgeon8,
  6. Jens Ivar Brox, consultant in physical medicine9,
  7. Jako Burgers, general practitioner10 11,
  8. Qiukui Hao, geriatrician, methodologist12 13,
  9. Teemu Karjalainen, hand surgeon7,
  10. Michel van den Bekerom, orthopaedic surgeon14,
  11. Julia Noorduyn, physiotherapist14,
  12. Lyubov Lytvyn, patient partnership liaison13,
  13. Reed A C Siemieniuk, general internist, methodologist13,
  14. Alexandra Albin, patient partner15,
  15. Sean Chua Shunjie, patient partner16,
  16. Florian Fisch, patient partner17,
  17. Laurie Proulx, patient partner18,
  18. Gordon Guyatt, general internist, methodologist13,
  19. Thomas Agoritsas, general internist, methodologist19,
  20. Rudolf W Poolman, chair, orthopaedic surgeon14
  1. 1Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway
  2. 2Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
  3. 3Finnish Center of Evidence based Orthopaedics (FICEBO), University of Helsinki, Helsinki, Finland
  4. 4Department of Orthopaedics and Traumatology, HUS Helsinki University Hospital, Helsinki, Finland
  5. 5Division of Physiotherapy, Linköping University, Linköping, Sweden
  6. 6School of Allied Health, La Trobe University, Melbourne, Australia
  7. 7Monash Department of Clinical Epidemiology, Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University
  8. 8Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
  9. 9Department of Physical Medicine and Rehabilitation, Oslo University Hospital and Faculty of Medicine, University of Oslo, Norway
  10. 10Dutch College of General Practitioners, Utrecht, The Netherlands
  11. 11Care and Public Health Research Institute, Department Family Medicine, Maastricht, The Netherlands
  12. 12Center of Gerontology and Geriatrics (National Clinical Research Center for Geriatrics), West China Hospital, Sichuan University, Chengdu, China
  13. 13Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.
  14. 14Department of Orthopaedic Surgery and Traumatology, Joint Research, OLVG, Amsterdam, The Netherlands
  15. 15Society for Participatory Medicine Member, USA
  16. 16MOH Holdings, 1 Maritime Square, Singapore
  17. 17Gryphenhübeliweg 28, 3006 Bern, Switzerland
  18. 18Canadian Arthritis Patient Alliance, Canada
  19. 19Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
  1. Correspondence: R W Poolman rwp{at}jointresearch.org

Abstract

Clinical question Do adults with atraumatic shoulder pain for more than 3 months diagnosed as subacromial pain syndrome (SAPS), also labelled as rotator cuff disease, benefit from subacromial decompression surgery? This guideline builds on to two recent high quality trials of shoulder surgery.

Current practice SAPS is the common diagnosis for shoulder pain with several first line treatment options, including analgesia, exercises, and injections. Surgeons frequently perform arthroscopic subacromial decompression for prolonged symptoms, with guidelines providing conflicting recommendations.

Recommendation The guideline panel makes a strong recommendation against surgery.

How this guideline was created A guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines and the GRADE system. The recommendation is based on two linked systematic reviews on (a) the benefits and harms of subacromial decompression surgery and (b) the minimally important differences for patient reported outcome measures. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of surgery in multilayered evidence summaries and decision aids available in MAGIC (www.magicapp.org) to support shared decisions and adaptation.

The evidence Surgery did not provide important improvements in pain, function, or quality of life compared with placebo surgery or other options. Frozen shoulder may be more common with surgery.

Understanding the recommendation The panel concluded that almost all informed patients would choose to avoid surgery because there is no benefit but there are harms and it is burdensome. Subacromial decompression surgery should not be offered to patients with SAPS. However, there is substantial uncertainty in what alternative treatment is best.

Footnotes

  • This BMJ Rapid Recommendation article is one of a series that provides clinicians with trustworthy recommendations for potentially practice changing evidence. BMJ Rapid Recommendations represent a collaborative effort between the MAGIC group (http://magicproject.org/) and The BMJ. A summary is offered here and the full version including decision aids is on the MAGICapp (https://app.magicapp.org), for all devices in multilayered formats. Those reading and using these recommendations should consider individual patient circumstances, and their values and preferences and may want to use consultation decision aids in MAGICapp to facilitate shared decision making with patients. We encourage adaptation and contextualisation of our recommendations to local or other contexts. Those considering use or adaptation of content may go to MAGICapp to link or extract its content or contact The BMJ for permission to reuse content in this article.

  • Competing interests: All authors have completed the BMJ Rapid Recommendations interest disclosure form and a detailed, contextualised description of all disclosures is reported in appendix 1 on bmj.com. As with all BMJ Rapid Recommendations, the executive team and The BMJ judged that no panel member had any financial conflict of interest. Professional and academic interests are minimised as much as possible, while maintaining necessary expertise on the panel to make fully informed decisions.

  • Funding: The Dutch Orthopaedic Society has provided the MAGIC Foundation with €35 000 to support development of two rapid recommendations for orthopaedic surgery. The society had no role in the guideline development process for this BMJ Rapid Recommendation. The recommendation on shoulder surgery will be adapted into an updated recommendation in their guidelines.

  • Transparency: R Poolman and P O Vandvik affirm that the manuscript is an honest, accurate, and transparent account of the recommendation being reported; that no important aspects of the recommendation have been omitted; and that any discrepancies from the recommendation as planned (and, if relevant, registered) have been explained.

  • Provenance and peer review: Commissioned; externally peer reviewed

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