Tuesday, February 19, 2019 CPG: Avoid Surgery for Atraumatic Shoulder Pain Authors of a new clinical practice guideline (CPG) on treatment of shoulder pain took a hard look at the advisability of surgery and came to a conclusion that can be boiled down to 3 words: don't do it. Published in BMJ, the CPG focuses on adults with atraumatic shoulder pain lasting for 3 months or more (diagnosed as subacromial pain syndrome, or SAPS), and zeroes in on the effectiveness of arthroscopic decompression surgery versus nonsurgical approaches including exercise therapy, analgesics, and injections. The CPG development group, which included patients who had experienced SAPS, analyzed results of 2 systematic reviews—one on what constitutes a "minimally critically important difference" (MCID) in patient-reported outcomes, and another on the benefits and harms of decompression surgery. The systematic reviews included 7 trials involving 1, 014 patients. In reviewing the systematic review of MCIDs for SAPS, the CPG group identified, with confidence, 2 changes that patients value: a difference in pain of at least 1.5 points on a visual 1-10 scale, and a difference in function of at least 8.3 units on a 100-point scale. In both areas, decompression surgery resulted in no significant differences from other approaches—including placebo surgery. The lack of difference remained at 6-month, 2-year, and 5-year follow ups. Authors of the CPG also looked at 6 trials that compared surgery with exercise therapy, and although all were at high risk of bias due to lack of blinding, the results indicated that surgery demonstrated no advantages over exercise therapy in terms of pain, function, quality of life, perceived effect, and return to work. Armed with the conclusion that decompression surgery isn't any more effective than sham surgery or other treatment approaches, the CPG authors next analyzed the benefits and harms of the procedure. Again, surgery didn't fare well. After the guideline panel found that "potential harms from surgery were incompletely reported in the trials," the group requested that the systematic review be expanded to include observational studies that evaluated harm after the procedure. They found 4 sets of results from a large US study that found a roughly 0.55% risk of complications after 30 days. The harms included bleeding, infections, peripheral nerve injury, anesthetic complications, and venous thromboembolism. Given the procedure's risks and apparent lack of superiority in terms of effectiveness, "the panel concluded that almost all well informed patients would decline surgery and therefore made a strong recommendation against subacromial decompression surgery," authors write. "Clinicians should not offer patients subacromial decompression surgery unprompted, and others should make efforts to educate the public regarding the ineffectiveness of surgery." As for the alternatives to surgery, authors state that "the whole area of best management of SAPS is uncertain," including exercise therapy, manual therapy, and electrotherapies. Current evidence on these approaches show "uncertain benefit to patients compared with watchful waiting, and guidelines vary in their recommendations," they write. Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.