Shoulder Pain Update
December 15th 2017 - Written by
Last month I wrote a short Facebook post discussing the importance of ensuring appropriate diagnosis for the causes of shoulder pain to ensure that patients subsequently receive appropriate treatment with the aim of maximising rehabilitation benefits. In summary I believe patients should know what they are dealing with so they can be helped to deal with it properly!
This update provides a summary of a recently published important research paper in the world of physiotherapy and orthopaedic medicine with regards to shoulder pain. I have tried to write this to benefit clinicians as well as patients.
One of the most common treatment modalities for sub-acromial shoulder pain ( the "weak and painful" shoulder mentioned in my Facebook post) is called arthroscopic sub-acromial decompression (ASAD). In recent times this surgery has been performed arthroscopically (keyhole) and involves the removal of the sub-acromial bursa and/or any excess bony growths of the acromion (this is the pointy bit at the very outer top of your shoulder). This surgery has been in existence since the 1970s despite any high quality research to support it.
A paper was recently published open access in the Lancet that investigated the effects of ASAD on what is clinically called sub-acromial pain syndrome/sub-acromial impingement syndrome/rotator-cuff related pain. Other terminology is often used interchangeably and I am not going to discuss today the "best" terminology to use, but this should be considered the most common cause of shoulder pain.
I have read many published comments, blogs, and opinions on social media since its publication, and as such the interest this paper has generated is clear. Therefore I would like to take this opportunity to commend the authors on their work. It is certainly hard to argue against the design and methodology of the study which in my opinion was of high quality (and this view has been echoed by many) in that it was randomised, took place across multiple locations, had appropriate numbers of participants, used validated outcome measures, and involved 3 separate groups for comparison. These points help ensure that the research findings are reliable, valid, and can be generalised across the population. It would also appear that the risk of bias is low particularly given it was funded by Arthritis Research UK, the National Institute for Health Research Biomedical Research Centre, and the Royal College of Surgeons (England).
As I have mentioned, participants of the study were randomly allocated to one of three groups. Group 1 received a true ASAD, group 2 received a placebo surgery (an incision and examination but no surgical repairs), and group 3 received no treatment. In short, the results of the study showed that at the 1 year follow-up mark there was no clinically significant benefit of the real surgery compared to the placebo surgery, and whilst there was a slight improvement compared to the no treatment group this was also considered not clinically important. I am not a statistician but I have not read any criticism so far of the interpretation and I cannot see any myself.
Needless to say this has raised some interesting points. The most notable being that whilst surgery might work in some cases, the results suggest it is not due to mechanisms proposed. Certain aspects of ASAD therefore may be entirely unnecessary. In fact the surgery may be entirely unnecessary This is of particular importance in that there are inherit risks of surgery such as developing a secondary frozen shoulder, infection, further surgery, nerve damage, and cardiac events to name but a few.
There are limitations to this study which are highlighted by the authors. It is my opinion that it is important to recognise that the study population above had a mean age of 53 for each group. Therefore the results may not hold true for a younger/athletic population whereby the mechanisms for shoulder “impingement” may be different. So whilst the results can be generalised to the most common presenting age group for sub-acromial pain, they cannot be generalised to all groups. Furthermore, as with any good study, there are strict inclusion/exclusion criteria (which can be found here). Therefore certain specific shoulder conditions and specific pathologies that lead to “impingement”, as indicated by clinical assessment and possible imaging modalities, may still be better suited to surgery.
Another limitation is that whilst physiotherapy was provided to both surgical groups post-operatively, there was no clear indication as to what this level of care was which this may have affected the outcome. To these best of my knowledge there is no clear approved protocol for post-operative rehabilitation. Part of the inclusion criteria for participants was that physiotherapy was to be provided for a period of time pre-operatively as well participants receiving at least 1 cortisone injection- this is generally accepted as best practice. However, there is no clear data as to what this physiotherapy entailed and how long for participants received it for. I wonder if the physiotherapy provided best evidence-based care and if not did this confound the study results? It should be noted that this variable across a multi-centre trial would be exceptionally difficult to control and as each patient is unique following a strict protocol may not be advisable anyway. I might also be mistaken, but I can’t find any information regarding the timing of injections pre-operatively, location, or name of the pharmaceutical agent and whilst this was not the key aim of the study perhaps it influences the results?
I will be the first to admit that whilst somewhat practised in the critiquing of papers (at undergraduate and masters’ level) that I am in no way an expert in synthesising the literature. That said I do feel confident enough to state that the above research should influence patient care. What should be of more definitive guidance is the consensus statement from the British Elbow and Shoulder Society (BESS) and however they eventually interpret the findings will likely be the most informed viewpoint.
I do believe that the above study adds further to body of evidence that physiotherapy should be the first line treatment for sub-acromial pain and potentially the best course of treatment for most cases of sub-acromial pain. In my experience, and in keeping with the research, appropriate rehabilitation can in many instances take up to 3-6 months, although each patient is different. (There are some factors that indicate if patients are likely to make a good recovery with conservative care. Interestingly these are not necessarily the clinical findings on X-rays/scan/assessment but more to do with lifestyle factors, mental health, and beliefs about physiotherapy). If at that stage patients still remain in high levels of pain, with low levels of function, and are being failed by a legitimate evidence-based rehab programme combined with injection therapy, then they could consider further investigations with a view to potential surgery. However they must be aware that the strongest current evidence suggests a “wait and see approach” in most instances will likely yield broadly similar results. I am very aware that many of my patients have benefitted from this surgery and perhaps patient selection is key, but currently the research is yet to indicate which patients these are.
I think one of the challenges for physiotherapists is going to be ensuring that they establish links with surgeons who are not "knife-happy" but will interpret imaging findings appropriately and in relation to the patient in front of them. This is important as most physiotherapists are not suitably qualified in reading images. It is equally important for surgeons to ensure that physiotherapists have given the best evidenced rehabilitation- as physios we should be duty bound to provide this. Collaborative working and mutual trust is undoubtedly key to enhancing patient outcomes.
The above study has such large potential ramifications to healthcare within the UK that it might require replication to ensure any guideline change is accurate. Therefore the following paper should be of interest and I would like to direct any readers that have endured the above information so far to the following study which is currently being undertaken.
FIMPACT will, similarly to the CSAW Trial, compare ASAD to placebo surgery, with the key difference being the third arm of the trial will include a specific guided physiotherapy group. Interestingly the exercise group will have 15 sessions of care (I believe this is in keeping with the evidence and should be food for thought for patients, clinicians, healthcare managers within the NHS, and insurance companies...). Having briefly read the trial protocol it looks like the 15 sessions will follow a protocol for physiotherapy which appears to have been created in 1993 (reference here). Whilst the 1993 paper appears to follow a progressive loading programme, I do feel it is likely outdated. However according to the trial, the protocol has apparently been updated by the original author. I am not quite sure what the update has involved but an initial criticism would be that there is good current evidence-based protocols of specific exercises designed by Holmgren et al, 2014. In my opinion it would have made sense to have incorporated this into the prospective study to increase the reliability of the results. Despite this initial short critique the results will undoubtedly be important in impacting future patient care.
As a final point for any of my current or future patients please note I am happy to discuss the pros and cons of ASAD as best I can, and I am also happy to offer a “second opinion” service as I believe that patients should be best-informed with regards to their healthcare. Should you then choose to progress with surgery Physiomac have some close professional links with some great surgeons that we can refer you to if required.
If you have any questions please get in touch with me at the clinic on 01292 318777 or by email at firstname.lastname@example.org.
Best wishes and thanks for reading,