PT professor works with research team to improve common shoulder surgery

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Assistant Professor of Physical Therapy Paul Salamh, along with experts from around the world, have published an article that has led to a rapid recommendation in the British Medical Journal. The article presents evidence that shows the ineffectiveness of the surgery compared to other forms of treatment and that it should not be the primary form of treatment done for subacromial pain syndrome, better known as shoulder impingement.

Shoulder impingement is the pain that occurs when the tendon between the ball and socket of the shoulder is injured and irritated due to a myriad of reasons. There are multiple forms of treatment for shoulder impingement such as medication and physical therapy to alleviate pain, according to the article published by Salamh and his colleagues. Another common form of treatment for shoulder impingement is subacromial decompression surgery, a surgery where part of the shoulder blade is shaved off in order to try to alleviate the pain. This treatment now has been proven ineffective and possibly dangerous by Salamh and his team in their research “Subacromial Decompression Surgery for Adults with Shoulder Pain: A Systematic Review with Metanalysis.”


According to Salamh, the research team examined more than 800 studies by prior researchers to conclude that the surgery provides no benefit over non-surgical treatment. The research consisted of several randomized trials that compared the surgery with placebo surgeries or exercises, according to the article. Salamh said the placebo trials demonstrated no significant differences compared to when the actual surgery is performed. When they saw these results, Salamh said, they knew that something needed to be changed.

“One of the big things that kind of led to this is there were placebo trials that had been going on [and] randomized controlled trials where people were either going in, unknowing to them, either having the surgery done to their shoulder or literally having the holes and the scopes put in, but no surgery performed,” Salamh said.  “There was no difference between pain, range of motion or function in those individuals in either group, and so that’s when people really started saying, ‘Whoa, whoa.’ We’ve known for a while that this [surgery] is suspect, but a placebo surgery trial is not something you hear about very often. So when that started happening, we knew the time was sort of right to do something along these lines.”

According to Salamh, he was one of the last members brought onto the team, as many of the others had already been doing shoulder impingement research. Originally, Salamh and a colleague were starting on a project similar to that of the team already in place. According to Salamh, he reached out to the team, provided his background and asked if they wanted to collaborate, and they agreed.  Salamh said he and his colleague did not set out to get a rapid recommendation. According to Salamh, he reached out to the team, provided his background and asked if they wanted to collaborate, and they agreed. The global team that Salamh joined had the goal of getting a rapid recommendation, which according to Salamh, is a very long process that takes a large amount of planning. Prior to their research, there had been only 13 rapid recommendations spanning topics such as HIV and cancer treatments. According to Salamh, this was only the second orthopedic rapid recommendation, the first of which was on the knee.

Salamh said he has spent most of his career as a researcher working with the shoulder, which  he said is uncommon because most physical therapists work with the entire body. At Duke University, Salamh said he first got into his shoulder research with younger children and others with shoulder pathology problems.

“[The shoulder is] something I’ve been interested in, even in my earlier days in undergrad,” Salamh said. “I had a shoulder surgery from participating in athletics myself, and it didn’t work out so well. After I graduated, I began working with an orthopedic surgeon who was a former head of Duke Sports Medicine, and he really worked on those individuals with shoulder pathology. So for 10 or 11 years, he and I just worked together, [him] as a surgeon and myself as a therapist working with athletes and individuals with the shoulder conditions. It’s kind of unusual to find yourself in a situation where you’re only dealing with individuals with a certain pathology.”

According to Salamh, this is the first time that his research has had such an impact. The team said they hope that the BMJ rapid recommendation will help reduce the number of people getting the surgery.

“This is the first time that I’ve really felt the research I’ve been a part of was something that would have a big impact,” Salamh said. “You’re talking about hundreds of thousands of people, if not more, having this surgery and the harms that come associated with it and the cost to the healthcare system. So the fact that our research can have an impact on changing that, it was the first time I felt like any of my research that I was a part of recent [there could be] some meaningful change that could happen. But the biggest thing now is how do we implement that change?”

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