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While we are supposed to be living in the era of evidence-based medicine (EBM), there is still a long distance between academic research and daily clinical practice. Clinicians love to cling to their safe havens and we often cite experience as a reason to uphold the status quo of clinical management. However, clinical experience can deceive us into thinking we know best, but in the age of evidence it seems rather anachronistic to hold experience above science when our opinions are being questioned.
EBM is not just about clinical experience and scientific studies, it includes patient preference. Although patient-centred care is an indisputable hallmark of modern medicine, a recent publication in JAMA highlighted patients’ tendency to overestimate treatment benefits and underestimate harms.1 Clinicians need to educate patients sufficiently and inform them about benefits and harms based on the best clinical evidence, to ensure that they make sound judgements about their own health.
Acromioplasty: the cornerstone of questionable surgery?
A number of studies have looked at the rising incidence of acromioplasty for the treatment of subacromial impingement syndrome or subacromial pain syndrome. A recent UK study reported a staggering 750% increase in the rate of these surgeries from 2000 to 2010.2 A Finnish study actually reported declining incidence of surgery in public hospitals; however, this positive development was balanced by an increase in the private sector.3 The numbers are not a problem in their own right. Had clinical outcomes been shown to consistently improve with surgery compared to conservative therapy, the increase could easily have been justified. Unfortunately, they have not.
Why are these surgeries still being performed?
For over 20 years, surgery has failed to provide superior outcomes compared to conservative therapy for the treatment of subacromial pain syndrome.4 The shoulder complex often leaves clinicians with frustrating uncertainty about the diagnosis, perhaps leading to poorly directed conservative management and opening the door for surgical opinion.5 The ambiguities are nicely illustrated by a 2009 study, which showed that a bursectomy alone had comparable effects to remove the acromion and bursa.
Additionally, as some of the structures being surgically removed for decreasing pain have a stabilising role in the shoulder complex, and to put it into context in another joint, the following quote seems appropriate: “It would be hard to imagine that a surgeon would suggest, or a patient would agree to, having the anterior cruciate ligament removed to treat knee pain.”6
Then there is the concept of placebo. Surgeons have generally been reluctant to perform placebo surgery and the reasons are of course multifaceted. Orthopaedic research that compares surgery with placebo surgeries has had equivocal results and created fierce debate within the scientific community. However, a recent systematic review does indeed show that the concept of placebo surgery is both warranted and ethically justified.7 In the words of Carl Sagan: “Extraordinary claims require extraordinary evidence.” And while the claims from orthopaedic research might not be extraordinary, orthopaedic surgery has enjoyed amnesty from scientific inquiry for far too long.8 While studies investigating placebo surgery for subacromial pain syndrome have not been conducted, 2015 may be the year we will see the first research providing answers to this question.
How do we fix the overuse of surgery for shoulder pain?
History is filled with examples of long delays in the dissemination, acceptance and implementation of high-level clinical evidence into clinical practice. Make no mistake, there are many unanswered questions within conservative care of shoulder pain. We definitely need more research, more honesty and more humility. But in the light of the current evidence, the benefits of surgical intervention for the treatment of subacromial pain syndrome seem glorified and overrated. Conservative treatment appears underutilised and underestimated.
The solution should be obvious. We need to deliver patient-centred, evidence-informed, high-quality treatment based on the very best of scientific rigour. We need to make conservative care attractive, accessible and affordable. We need to educate the public. We need to let patients know that exercise will have results similar to surgery and that it will be cheaper and have more profound, long-lasting effects on patients’ health.
In other words: We need to make exercise as sexy as the scalpel.
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