Physio findings: sling and exercise work as well as surgery for shoulders

Janet Wright looks at newly published studies.

Sling and exercise work as well as surgery for shoulders

Shoulder fractures are becoming increasingly common in older people, and more patients are being offered surgery despite a shortage of clear evidence that it is effective. 
A five-year study has now found that surgery is no more successful than the conservative treatment: simply immobilising the arm with a sling and having physiotherapy.
Amar Rangan of James Cook University Hospital, Middlesbrough, and colleagues carried out the biggest randomised trial to date on this kind of fracture. They recruited 250 patients, with help from clinicians at 32 NHS hospitals around the country.
The patients had all had a fracture within the previous three weeks. They were randomly allocated to two groups, with 114 receiving surgery while 117 wore a sling to immobilise the arm, followed by physiotherapy. 
The Proximal fracture of the humerus evaluation by randomization (PROFHER) trial took place in several centres. The team developed a rehabilitation routine with input from specialist physios and produced an information leaflet on self-care for patients wearing a sling. Patients were also given exercises to do at home, and reported on their own outcomes.
Along with the standardised physiotherapy protocols, specially designed forms helped to ensure that treatment and record-keeping remained the same in each centre. 
‘There was exemplary completion of the physiotherapy forms that often reflected a complex patient care pathway,’ says a related paper about the trial. 
The patients were followed up at six months, a year and two years later. Researchers found no significant difference between those who had and hadn’t undergone surgery in terms of function, pain, health-related quality of life, complications related to the surgery or fracture, or death. 
‘These results do not support the trend of increased surgery for patients with displaced fractures of the proximal humerus,’ say the authors. Rangan A et al. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: The PROFHER randomized clinical trial. JAMA 2015; 313: 1037-1047.  Handoll HHG et al. Developing, delivering and documenting rehabilitation in a multi-centre randomised controlled surgical trial: Experiences from the PROFHER trial. Bone & Joint Research 2014; 3: 335-340- open access.

Open access

Most journals only allow non-subscribers to read the abstracts, or summaries of studies they’ve printed. To read the full study you usually need a subscription, or access through your workplace or an institution such as the CSP. (See ‘Reading keeps you up to date’, Frontline 18 February 2015). However, a growing number of journals allow all or some of their work to be read free of charge online, as part of a movement for open access. Starting this issue, stories in Physio findings that can be read in full by anyone will be labelled ‘open access’.

Physiotherapy is worth the cost to US patients

Lumbar spinal stenosis is a painful condition, caused when joint degeneration or age-related changes reduce the space around the spinal cord. The resulting pressure on the spinal nerves can cause pain in the lower back and legs, making it difficult to walk. 
Anthony Delitto from Pittsburgh University and colleagues compared two popular treatments: physiotherapy and surgical decompression. They chose 169 volunteers over the age of 50 whose spinal stenosis had been diagnosed by CT or MRI scans who had all been found suitable for surgery. 
The team randomly allocated patients for either decompression surgery or physiotherapy. The physiotherapy group attended twice-weekly sessions for six weeks, which included patient education as well as exercises in lumbar flexion and general conditioning.
However, more than half the physio group chose to swap and have the operation after the trial started, most of them having had a few exercise sessions.  As the trial took place in the United States, the team noted that healthcare costs may have played a role: physiotherapy worked out more expensive to the patients than an operation.
Both groups were assessed four times over the following two years. After the final assessment, the team concluded that both physiotherapy and surgery had yielded similar results. 
‘Patients and health care providers should engage in shared decision-making conversations that include full disclosure of evidence involving surgical and nonsurgical treatments for LSS,’ the authors conclude. Delitto A et al. Surgery versus nonsurgical treatment of lumbar spinal stenosis: A randomized trial. Annals of Internal Medicine 2015.

Comments and conclusions

A Pilates programme proved as effective as conventional pelvic-floor muscle exercises in treating urinary incontinence in men after a prostatectomy. Pedriali FR et al. Neurourology and Urodynamics 2015.
Ten-year-olds in the UK now are two to three times more likely to be obese than children born before the 1980s, say researchers studying data on 56,632 people in five British studies. People are becoming overweight earlier and reaching higher weights in each generation. Johnson W et al. PLOS Medicine 2015;  - open access 
Janet Wright

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