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‘Physio’s not going to repair a torn tendon’: patient decision-making related to surgery for rotator cuff related shoulder pain

Review written by Andrew Cuff info

Key Points

  1. The rates of surgery for rotator cuff related shoulder pain (RCRSP) are increasing despite uncertainty around effectiveness and efficacy.
  2. Personalized care involves the provision of adequate and accurate information to inform shared decision-making.
  3. The decision-making process underpinning whether an individual decides to proceed with surgical intervention is multifactorial, and inclusive of internal and external factors.

BACKGROUND & OBJECTIVE

Shoulder pain is the third most common body site for musculoskeletal (MSK) pain, affecting 1 in 4 of us across our lifespan (1). Rotator cuff related shoulder pain (RCRSP) is considered to be the most common cause of shoulder pain (2). Surgery for RCRSP often consists of two main procedures: either a subacromial decompression, or rotator cuff tendon repair. Decompression surgery has been shown to not outperform placebo surgery for improving pain or function at up to 12-months follow up (3), whilst in those undergoing tendon repair, 40% demonstrate a failed repair without a compromise in function at two years.

Despite this uncertainty around surgical intervention, the rates of surgery are increasing across the world. The objective of this review was to explore the decision-making rationale in people who have undergone surgery for RCRSP.

Shoulder pain is the third most common body site for musculoskeletal pain, affecting 1 in 4 of us across our lifespan.
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The decision to proceed with surgery is often based on an outdated pathoanatomic model of shoulder pain involving the acromion, tears, and prognosis.

METHODS

A qualitative investigation was performed using semi-structured interviews as the data collection method. Each participant had undergone surgery for RCRSP in the last 12-months. The interviews were structured using a topic guide that had been developed by the research team.

Each interview lasted up to 45 minutes and was transcribed verbatim prior to being thematically analyzed. Recruitment into the study was completed when data saturation was reached, defined as when no new themes were emerging with subsequent interviews.

The study involved a sample of 15 participants. The credibility of the data obtained was enhanced through the use of various methods including member checking, reflexivity and peer-debriefing.

RESULTS

The interviews revealed six themes that underpin the decision-making process for people with RCRSP that go on to have surgery. These include:

  1. Needing to get it done – due to the impact on quality of life, surgery was considered the only viable option to alleviate discomfort.
  2. Non-surgical treatment experience – all participants had initial non-surgical intervention that resulted in unsatisfactory outcomes from the perspective of the person.
  3. Mechanical problem – the understanding of the problem was framed and understood from a biomedical perspective.
  4. Trust in medical professionals – there was overwhelming trust in the opinion of the surgeon with uncritical consideration; whilst non-surgical healthcare professional opinion was considered more critically.
  5. Varied information sources – information provided by health professions was valued to inform decision-making; the majority had also consulted the internet to aide understanding.
  6. Organisational barriers – the costs of the surgery, and the option being available or not under their insurance cover also influenced decision-making.

LIMITATIONS

A key strength of this qualitative investigation included the triangulation of different methods to increase the credibility and rigour of the findings. This included member checking, reflexivity, and peer-debriefing.

A limitation of this paper however includes the lack of transparency regarding the theoretical perspective of the research team, i.e. their ontology, epistemology and how this influenced their methodology.

CLINICAL IMPLICATIONS

Personalized care and shared decision-making are at the centre of high-value clinical care. This involves providing adequate information regarding the risks and benefits of treatment options to allow an informed decision. This study highlights the importance of this in the context of RCRSP when considering surgery, especially given the underlying uncertainty around its efficacy.

Despite the uncertainty within the published literature and healthcare community, this does not appear to have filtered down to a public level, as this study showed there is often uncritical consideration of a surgeon’s opinion. The decision to proceed with surgery is often based on an outdated pathoanatomic model of shoulder pain involving the acromion, tears, and prognosis. This needs consideration in the context of imaging findings in an asymptomatic population, as well as the empirical evidence on surgical treatments.

Within clinical practice, care should be taken to ensure that an explanation of symptoms is congruent with contemporary understanding of pain science, the impact of metabolic factors, and wider determinants of health including social factors. This is important in order to provide an individualized explanation of why someone may be experiencing shoulder pain, the contributory factors and in turn, targets, and personalized management of these factors.

This may or may not include surgical intervention, but when indicated, the person with shoulder pain should have adequate and accurate information on which to base their decision.

+STUDY REFERENCE

Malliaras P, Rathi S, Burstein F, Watt L, Ridgway J, King C & Warren N (2021) ‘Physio’s not going to repair a torn tendon’: patient decision-making related to surgery for rotator cuff related shoulder pain. Disability and Rehabilitation. Online ahead of print.

SUPPORTING REFERENCE

  1. Ottenheijm RP, Joore MA, Walenkamp GH, et al (2011) The Maastricht Ultrasound Shoulder pain trial (MUST): ultra-sound imaging as a diagnostic triage tool to improve management of patients with non-chronic shoulder pain in primary care. BMC Musculoskelet Disord, 12:154.
  2. Van Der Windt DA, Thomas E, Pope DP, et al (2000) Occupational risk factors for shoulder pain: a systematic review. Occup Environ Med. 57(7), 433–442.
  3. Karjalainen TV, Jain NB, Page CM, et al (2019) Subacromial decompression surgery for rotator cuff disease. Cochrane Database Sys Rev.1(1):CD005619.
‘Physio’s not going to… By Andrew Cuff