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Top POEMs of 2018 Consistent with the Principles of the Choosing Wisely Campaign: Musculoskeletal Conditions

Top 20 POEMs of 2018 Consistent with the Principles of the Choosing Wisely Campaign

Decompression Surgery No More Effective Than Exercise for Shoulder Impingement Syndrome

Clinical question
In patients with symptoms of shoulder impingement syndrome is subacromial decompression surgery more effective than sham arthroscopy or exercise therapy to decrease pain and improve function?

Bottom line
Despite being one of the most common orthopedic surgeries performed, subacromial decompression is not significantly better than physical therapy to treat patients with pain and limited function due to shoulder impingement. This study is backed up by a meta-analysis that found the same results (doi:10.3109/09638288.2014.907364). Get out the stretchy bands or hand weights: another meta-analysis (doi:10.1136/bjsports-2016-096515) demonstrated the benefit of shoulder exercises over other physical therapy modalities. (LOE = 1a)(www.essentialevidenceplus.com)

Reference
Paavola M, Malmivaara A, Taimela S, et al, for the Finnish Shoulder Impingement Arthroscopy Controlled Trial (FIMPACT) Investigators. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial. BMJ 2018;362:k2860.

Study design: Randomized controlled trial (double-blinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (specialty)

Synopsis
These Finnish researchers enrolled 210 adults aged 35 to 65 years with a clinical presentation of shoulder impingement syndrome who, by magnetic resonance imaging, had no evidence of rotator cuff tear and who had not responded to 3 months of conventional treatment. The patients were first randomized to receive surgery or physical therapy using concealed allocation; patients tapped for surgery underwent diagnostic arthroscopy to rule out tears or other pathology and then, in the operating room, were randomized again to receive arthroscopic subacromial decompression or (to keep everyone unaware of treatment assignment) kept in the operating theater but without further intervention for the length of time of a typical decompression. After 2 years, patients in all 3 groups had a large decrease in reported pain, from approximately 75 to between 20 and 30 on a 100-point visual analog scale. Decompression was statistically better than exercise therapy, but the result would not be clinically relevant (a difference of at least 15 points) and was no different than diagnostic arthroscopy. There was also no difference in pain or function scores at earlier time points. The researchers did not attempt to stratify patients by degree of joint narrowing or by the presence of osteoarthritis or other morphology, and targeted therapy aimed at specific changes may have found a difference in treatment outcomes.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Surgery = No Surgery for Patients with Subacromial Shoulder Pain (CSAW)

Clinical question
Do patients with subacromial shoulder pain for at least 3 months who are treated surgically have better outcomes than those who are treated without surgery?

Bottom line
In patients with subacromial shoulder pain of at least 3 months duration who receive physical therapy, surgical decompression is no better than arthroscopy without decompression in improving pain or function… and neither is much better than no invasive intervention at all. (LOE = 1b)(www.essentialevidenceplus.com)

Reference
Beard DJ, Rees JL, Cook JA, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet 2018;391(10118):329-338.

Study design: Randomized controlled trial (double-blinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (specialty)

Synopsis
These authors randomized adults with subacromial pain of at least 3 months duration into 1 of 3 groups: arthroscopic decompression of the acromion (n = 106), arthroscopy without decompression (n = 103), or no additional treatment (n = 104). Before enrollment, all patients underwent physical therapy and had at least one corticosteroid injection. The authors excluded patients with complete rotator cuff tears. A healthy percentage of the patients (23%, 42%, and 12%, respectively) allocated to decompression, arthroscopy only, and no treatment did not receive their assigned treatment by 6 months because they were already better! Additionally, approximately 15% of the patients did not complete 12 months of follow up. After 6 months and 1 year, the patients treated with either surgical decompression or arthroscopy without decompression had improvements in pain and function (as measured by the Oxford Shoulder Score) compared with patients who received no treatment, but the differences were not clinically important. Additionally, there was no difference between the decompression and arthroscopy without decompression groups. Two patients in each group developed adhesive capsulitis. The authors don't report on surgical complications.

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI

Amitriptyline Ineffective for Chronic Back Pain

Clinical question
Is low-dose amitriptyline effective for the management of chronic lower back pain?

Bottom line
When compared with a similarly mouth-drying placebo (the anticholinergic benztropine), low-dose amitriptyline provides no greater improvement after 3 months and 6 months of treatment in patients with well-established low back pain. (LOE = 2b)(www.essentialevidenceplus.com)

Reference
Urquhart D, Wluka A, van Tulder M, et al. Efficacy of low-dose amitriptyline for chronic low back pain. JAMA Intern Med 2018;178(11):1474-1481.

Study design: Randomized controlled trial (double-blinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (any)

Synopsis

These researchers recruited (through general advertising) 146 patients with a history of low back pain. The patients had an average of more than 14 years of back pain. Average pain scores at the start of the study were in the mild range (40 to 43 on a scale of 0 to 100) and disability scores were also low (7.5 to 8.2 on a scale of 0 to 23). The patients were randomized, using concealed allocation, to receive either amitriptyline 25 mg or benztropine 1 mg at bedtime. Benztropine causes similar side effects to amitriptyline, but is not known to be effective for low back pain. Analysis was by intention to treat, though there were significant dropouts in both groups (18% to 20%), most due to side effects. At both 3 months and 6 months, average pain and disability scores were decreased in both groups, but neither reduction was clinically significant. There was no significant difference between reports of pain at 3 months or 6 months. Disability scores were better at 3 months in the amitriptyline group but not at 6 months. There was also no difference in patients' global assessment or general health status. The study did not have the power to find a difference if one existed, though the overall improvement, even if different, is not likely to be clinically relevant.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com(www.essentialevidenceplus.com).

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