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Common op may offer no extra benefit in reducing shoulder pain

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One of the most common surgical procedures used in orthopaedics may make very little difference when it comes to reducing shoulder pain, suggests a ground-breaking UK trial.

The trial to investigate the effectiveness of decompression surgery – often used to treat subacromial shoulder pain – found the technique offers no extra benefit when compared with “placebo surgery”.

“Surgery might not provide a clinically significant benefit over no treatment”

Andrew Carr

Meanwhile, both real and pretend surgery appeared to be only very slightly more effective at reducing pain than having no treatment at all, noted the researchers.

Those behind the study, published this week in The Lancet, said their findings called into question the value of the operation, which is performed on thousands of patients each year in England.

“Over the past three decades, patients with this form of shoulder pain and clinicians have accepted this surgery in the belief that it provides reliable relief of symptoms, and has low risk of adverse events and complications,” said co-chief investigator Professor Andrew Carr, from Oxford University.

“However, the findings from our study suggest that surgery might not provide a clinically significant benefit over no treatment, and that there is no benefit of decompression over placebo surgery,” he said.

Decompression surgery is a form a keyhole surgery that involves removing a small area of bone and soft tissue in the shoulder joint, with the aim of freeing up the joint and preventing rubbing or catching when the arm is lifted.

The study, which involved 32 hospitals and 52 surgeons across the UK, saw more than 270 patients who had suffered shoulder pain for at least three months assigned to one of three different courses of treatment.

“Other ways to treat shoulder impingement could be considered”

David Beard

Some underwent decompression surgery, while others had “placebo surgery” where surgeons looked inside the joint but did not remove any tissue. Both the groups that had surgery went on to receive some physiotherapy. Meanwhile, a third group received no treatment at all.

All patients who took part in the trial completed questionnaires about their level of pain and shoulder joint function six months in – scoring pain on a 0-48 scale, with a higher number meaning less pain.

At six months, patients who had decompression surgery and those who had placebo surgery rated their pain and function at a similar level – 32.7 and 34.2, respectively.

Both forms of treatment showed a small benefit, compared with no treatment at all, with patients in the no treatment group scoring pain and function 29.4. However, the researchers said this difference was unlikely to result in a noticeable difference in symptoms.

The research team said there may be a number of reasons for their results. These included a “placebo effect” from surgery – where people felt better simply because they have had some form of intervention – or an opposite “nocebo effect” among those who did not get further treatment.

There may also have been some unintended effects of the placebo surgery, or the results may be linked to the fact that those who had surgery also had phsyio and were told to rest.

Meanwhile, there were some limitations to the study including long waiting times that meant some who had only just had surgery and were still recovering were compared with patients who had received no treatment for six months.

However, the team said their findings did place a question mark over the benefit of decompression surgery.

“Our findings call into question the value of shoulder decompression surgery for this group of patients, and should be communicated to patients and doctors considering this type of surgery,” said co-chief investigator Professor David Beard, also from the University of Oxford.

“In light of our results, other ways to treat shoulder impingement could be considered, such as painkillers, physiotherapy and steroid injections,” he added.

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