http://www.ncbi.nlm.nih.gov/pubmed/24395315 - this interesting study from the BJJ opens up a huge can of worms for shoulder surgeons - perhaps the study is underpowered - but the results are certainly food for thought - and it will be fascinating to see if these results can be replicated with >100 patients in each arm.
The evidence is mounting rapidly demonstrating that many popular orthopedic procedures; including RC repair, arthroscopic meniscectomy, and various lumbar spinal procedures, are no better than conservative treatments, like physical therapy. However, orthopedic surgeons' average income continues to rise sharply according to the 2013 Physician Compensation Report (link below). Since 2011, their income has increased 27% on average. That's pretty steep- particularly in this economy. In fact, orthopods lead all medical specialties in average income. I'm not saying that orthopedic surgeons shouldn't be well-paid, but when you look at their outcomes compared to much less expensive options, you have to wonder what literature they- and the insurance companies that pay them- are reading.
http://www.medscape.com/features/slideshow/compensation/2013/public
A very good point. I think in the UK certainly, commissioners are going to stop paying for certain procedures unless it can be conclusively proven they are of benefit.
Interesting also how little we know about the natural history of certain diseases.....
These are all encouranging findings in my opinion as well. Good for the profession of physiotherapists.
But, we also must interper the studies as they are and not deem all surgery on these specific areas as non-effective. We should always keep in mind for example the differences of "degenerative tear" and "traumatic tear" as well as the patient population 20yo athletes compared to 60yo office worker. For these studies on meniscus and rotator cuff tears, the population where these operations have been deemened non-efficient has been older and the injury type has been non-traumatic or degenerative. So at least to me, it doesn't even come as a surprise that surgery doesn't work. Tissue quality in 65yo rotator cuff might not the best for refixation either.
But in general, good results and as said, food for thought!
Jukko,
The question is why are so many patients with persistent knee and shoulder pain undergoing arthroscopic procedures to "debride" a joint just because the patient has symptoms with concurrent findings of degenerative changes on imaging? These procedures continue to be done on a routine basis despite the lack of comparative effecfiveness to conservative therapies, particularly intervention by a PT.
I attended a presentation by a physician last week addressing the lack of effective and appropriate primary care for patients with osteoarthritis. In her presentation, she referenced the research suggesting that knee arthroscopy is not indicated unless the patient demonstrates "mechanical symptoms". When I asked what "mechanical symptoms" included, she didn't know and none of the physicians, residents and medical students in the room offered an interpretation. I suggested that this very specifically meant joint locking due to an internal derangement or loose body. I think many primary care physicians will interpret "mechanical symptoms" to include giving way or frequent popping or clicking in the joint, and so then the patient is sent off to the orthopedic surgeon, who will frequently convince the patient to undergo arthroscopy.
It seems that definitions like "mechanical symptoms" are purposely left ill-defined so that the most liberal interpretation can be made that allows for the most invasive and typically least cost-effective intervention. Our modern health care systems cannot afford any longer to be this liberal in doling out health care.
John,
I agree with you said and my intention was to point out that there needs to be a true indication for procedures done. Degenerative findings most likely are not good indications, but as you said, loose bodies and such might be. So therefore, there are patients who might need meniscus or rotator cuff surgery and patients who most definitely don't. Patients with osteoarthritis related symptoms (if these symptoms ever even are due to any pathoanatomical variant) seem to belong mostly in the latter group and not benefit from surgery.
OA patients also present with worse tactile acuity, that together with the findings about surgery and the non-correlation on imaging to their symptoms definitely points out to a more broad mechanism behind their symptoms than just what is or is not happening inside the joint.
Mind blowing......thanks for posting.
But Physios have to play a major role both in screening process and a rehab.
As a physiotherapist, it is encouraging that there is a growing amount of research to support that the rehabilitation we provide is effective. I am wondering if the management of painful shoulder conditions should go a step further and instead of spending time and effort coming to a diagnosis (with the exception of ruling out more sinister pathology) and tailoring treatment, it might be better to just block out the pain using a suprascapular nerve block and give the patient a generic rehab programme.
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