Subacromial decompression surgery for adults with shoulder pain: a clinical practice guidelineBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l294 (Published 06 February 2019) Cite this as: BMJ 2019;364:l294
Visual summary of recommendation
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- Per Olav Vandvik, methods co-chair, general internist, methodologist1 2,
- Tuomas Lähdeoja, orthopedic surgeon3 4,
- Clare Ardern, physiotherapist5 6,
- Rachelle Buchbinder, rheumatologist, methodologist7,
- Jaydeep Moro, orthopaedic surgeon8,
- Jens Ivar Brox, consultant in physical medicine9,
- Jako Burgers, general practitioner10 11,
- Qiukui Hao, geriatrician, methodologist12 13,
- Teemu Karjalainen, hand surgeon7,
- Michel van den Bekerom, orthopaedic surgeon14,
- Julia Noorduyn, physiotherapist14,
- Lyubov Lytvyn, patient partnership liaison13,
- Reed A C Siemieniuk, general internist, methodologist13,
- Alexandra Albin, patient partner15,
- Sean Chua Shunjie, patient partner16,
- Florian Fisch, patient partner17,
- Laurie Proulx, patient partner18,
- Gordon Guyatt, general internist, methodologist13,
- Thomas Agoritsas, general internist, methodologist19,
- Rudolf W Poolman, chair, orthopaedic surgeon14
- 1Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway
- 2Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
- 3Finnish Center of Evidence based Orthopaedics (FICEBO), University of Helsinki, Helsinki, Finland
- 4Department of Orthopaedics and Traumatology, HUS Helsinki University Hospital, Helsinki, Finland
- 5Division of Physiotherapy, Linköping University, Linköping, Sweden
- 6School of Allied Health, La Trobe University, Melbourne, Australia
- 7Monash Department of Clinical Epidemiology, Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University
- 8Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
- 9Department of Physical Medicine and Rehabilitation, Oslo University Hospital and Faculty of Medicine, University of Oslo, Norway
- 10Dutch College of General Practitioners, Utrecht, The Netherlands
- 11Care and Public Health Research Institute, Department Family Medicine, Maastricht, The Netherlands
- 12Center of Gerontology and Geriatrics (National Clinical Research Center for Geriatrics), West China Hospital, Sichuan University, Chengdu, China
- 13Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.
- 14Department of Orthopaedic Surgery and Traumatology, Joint Research, OLVG, Amsterdam, The Netherlands
- 15Society for Participatory Medicine Member, USA
- 16MOH Holdings, 1 Maritime Square, Singapore
- 17Gryphenhübeliweg 28, 3006 Bern, Switzerland
- 18Canadian Arthritis Patient Alliance, Canada
- 19Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
- Correspondence: R W Poolman
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.
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