In other physical therapy news

Popular Shoulder Procedure Provides ‘No Relevant Clinical Benefit' Over Placebo

Researchers in Finland have conducted a study that used "placebo surgery" to conclude that a frequently used arthroscopic procedure likely offers little to no benefit.
Subacromial decompression surgery for shoulder impingement was found to be no better than diagnostic arthroscopy alone. The procedure also was compared with physical therapy alone, but researchers are uncertain about the reliability of those results.
The study, published in BMJ, compared shoulder pain at rest and with arm activity among 122 participants, aged 35 to 65, who presented with shoulder impingement occurring for at least 3 months that was unresponsive to "conventional treatment."
Participants agreed to undergo arthroscopic surgery and understood that they might receive either simple diagnostic arthroscopy with no other surgical procedure or arthroscopic subacromial decompression surgery (ASD)—a procedure that involves smoothing the undersurface of the acromion in hopes of easing the passage of the rotator cuff tendon through the subacromial space. The authors characterized ASD as "one of the most frequently performed orthopaedic procedures in the world."
The researchers were careful to avoid introducing any hints as to who received which procedure, even going so far as seeing to it that the surgeons themselves didn't know which procedure they were performing until after the initial diagnostic arthroscopy—when a nurse opened a sealed envelope telling the surgeon whether to proceed with ASD or to end the procedure. Additionally, patients who did not receive ASD were kept in the surgical room for the time it would have taken to conduct the procedure, and no other facility staff were told which patients received which kind of surgery.
Both groups received the same postoperative care—a single visit to a PT "for guidance and instructions for home exercises." The PT also was in the dark about whether the participant had received ASD or placebo surgery.
After 24 months, the researchers measured participants' shoulder pain at rest and during arm activity by using a 0-100 visual analogue pain scale. Secondary outcomes were related to shoulder function and assessed through a Constant-Murley score and the 15D, a health-related quality of life measure. All 24-month assessments were compared with those captured at baseline and 3, 6, and 12 months postsurgery.
Researchers noted "marked improvement" among all participants. But that's what was so revealing—it didn't seem to matter whether the patient had received ASD or the placebo. The results were consistent for both pain and function assessments.
The study's authors wrote that the findings are strengthened by what they described as the "stringent eligibility criteria" used to select only participants "most likely to benefit from ASD."
"Classically, stringent eligibility criteria are considered to decrease the validity of a study," the authors wrote. "Although our patient population was indeed highly selected…we think that the use of stringent eligibility criteria paradoxically increases the generalizability of our findings. When ASD was proven futile under this best case scenario, there is no reason to assume that it would work better under less optimal circumstances or in a more heterogeneous population."
The researchers also compared the surgery groups with a third group of participants who participated in 15 sessions of physical therapy. While they found no significant differences in outcomes at 24 months, the authors cautioned against reading too much into those results, primarily because participants in the exercise group weren't weeded out as thoroughly as were those in the surgery group beforehand. "Thus the ASD versus exercise therapy comparison is likely to be biased in favor of ASD owing to systematic removal of patients with likely poorer prognosis [in the ASD group]," the authors wrote.
The study's approach was similar to that of a 2014 research project—also from Finland—that looked into arthroscopic surgery for meniscal tears. Like the shoulder study, the meniscal study involved the use of placebo surgery and found a similar lack of difference in outcomes between those who received the sham meniscal surgery and those who received the real thing.
As for the shoulder study, the authors were nothing if not direct in their assessment of the findings: "The results of this study…show that [ASD] provides no clinically relevant benefit over diagnostic arthroscopy in patients with shoulder impingement syndrome," they wrote. "The findings do not support the current practice of performing subacromial decompression in patients with shoulder impingement syndrome."