Wellness Life
By Gabriel De Carvalho
DOES SUBACROMIAL DECOMPRESSION SURGERY RELIEVE SHOULDER IMPINGEMENT? l Every year, up to one in fifty British adults visit their GP complaining of growing pain and stiffness in their shoulder. Most will be diagnosed with shoulder impingement, a condition where inflammation causes the tendons and bones in the shoulder to rub together resulting in painful pinching and increasingly restricted movement. Shoulder impingement can leave a person struggling to drive, lift their arm, dress themselves or function at work. If rest, exercise, pain relief and steroid injections fail to provide relief, doctors usually recommend subacromial decompression surgery. This common procedure is performed on 21,000 individuals each year. However, the results of a recent clinical trial question its usefulness, leaving many asking whether it should be offered as a treatment at all. In shoulder impingement, one of the tendons that make up the rotator cuff (a layer of tendons surrounding the ball and socket joint of the shoulder) becomes worn and painful. The tendon swells as it rubs on the bone and ligaments around it. The more irritated and swollen the joint becomes, the more it rubs, which increases swelling and results in a vicious cycle that is hard to break. Decompression surgery interrupts this cycle by providing more space within the joint for the tendon to move. During the procedure, the surgeon removes inflamed bursa (a fluid-filled sack separating the tendons and bone in the shoulder) and reduces the size of the acromion bone (a bone that sits above the shoulder’s ball and joint socket). Three to six months after surgery, around 75-90% of people report an improvement in their symptoms. After surgery, patients follow a programme of regular exercises and stretches (usually 5-10 minutes four times per day) under the guidance of a physiotherapist. But for 10-25% of people, surgery doesn’t work. A lack of improvement could be down to being misdiagnosed in the first place, patients not following postsurgical instructions (not regularly doing the exercises), or the surgeon not removing enough bone. However, a recent clinical trial hints at a deeper issue. The trial divided a large group of people diagnosed with shoulder impingement into three groups: patients who underwent subacromial decompression surgery, patients given placebo surgery (the surgeon made an incision but did not remove any bone or bursa) and a group who only followed an exercise plan. There was no significant difference in symptom improvement between the three groups. For patients, this means that having surgery offered them no additional benefit in the relief of pain, improved function or better quality of life. Which raises the question, if both having surgery and simply believing they’d had surgery produced the same result for patients, why do so many feel that it works?
4 HEALTHY READING MAGAZINE
The post-operative rehabilitation regime may be the answer. Neither surgery group showed much more improvement than the exercise-only group. So, is a course of physiotherapy actually the best answer for sufferers of shoulder impingement? Things may not be so clear-cut. Most patients are offered ‘first line’ treatments before their GP considers surgery, including a period of exercise and stretching under the care of a physiotherapist. If this doesn’t relieve symptoms, a GP suggests subacromial decompression surgery. If physiotherapy didn’t work before surgery, why would it work after? It may be that the experience of undergoing surgery motivates patients to stick to the rigid and lengthy exercise regime. Alternatively, physiotherapists might be better at motivating post-operative patients. If surgery is the final option, both patients and health care professionals may be more determined to make it work. This is not to say that surgery and exercise are the only options. Alternatives include rest, pain management techniques, steroid injections and acupuncture, none of which are problemfree. Steroid use can reduce bone density, avoiding using the joint can lead to frozen shoulder and research into the effectiveness of acupuncture is inconclusive. For the 21,000 people due to undergo subacromial decompression surgery this year, the placebo surgery trial may be a source of anxiety. But, while the results should start a conversation, the case is far from closed. GPs might just be a little keener to get their patients exercising before putting them forward for surgery in the future.
KEEPING YOUR BACK HEALTHY WHILE GARDENING l As days get longer and Spring approaches, it’s time for gardeners to get off the sofa and get to work. Now is the ideal time to get to grips with groundwork, soil preparation and landscaping projects to shape the garden for summer. However, be wary when taking on tough jobs. Like the weather, your muscles need time to really warm up, so pacing your projects will avoid aches and strains or worse. Back injuries among gardeners are common. Even if you have a regular winter fitness regime, muscles used for digging, lifting and kneeling are very likely underused and need retraining to rebuild strength.
WARMING UP AND STRETCHING
Most gardening tasks involve bending forward – taking your spine out of its natural posture. This puts a strain on the muscles, ligaments and vertebrae in the spine as it reverses our natural spinal curve. If you regularly practice yoga or pilates, it is likely you do exercises that strengthen and mobilise the back already. If not, consider taking a regular class. Massage can also help mobilise tight muscles ready for work. Whatever your exercise regime, you can reduce risk of strain with simple stretches before you begin gardening. For example, warming up the lower back muscles by lying on your back with knees bent in towards the chest, and gently swiveling your legs and knees from side to side. A trainer, physiotherapist or massage therapist should be able to advise on appropriate stretches.
GARDENING GEAR
Your feet take a lot of strain so wear strong, supportive boots that protect your ankles and feet. Any ankle strains or sore feet will affect your posture, and therefore your back. Protect knees too with a kneeling pad. Stiff or sore knees also impact your posture and movement. Use tools that suit you – spades and forks that are too short will put additional strain on your back, as will tools that are too heavy for you. Long handled tools can reduce the amount of forward bending you do. Also, a wheelbarrow will help to shift those heavy loads.
TAKE BREAKS
Whether digging, reaching to prune or moving pots around, you will be bending forward. It’s tempting to keep going until a job is done, but to protect your back it’s essential to take regular breaks from repetitive movement – at least every 30 minutes is recommended. Change position by standing up to admire your work. Counter stretch your back by standing upright with hands on the base of the spine and gently bending backwards a few times. The mental health benefits of gardening are increasingly recognised, so taking a more relaxed approach will benefit your mind as well as your body.