Do you provide diagnostic labels for patients? Depending on the perceived severity of the label, they could be harmful. One study of 1,308 participants showed labeling rotator cuff disease as bursitis decreased the perceived need for shoulder surgery compared with labeling it as a rotator cuff tear. There was also a reduction in the perceived need for imaging. These were isolated cases where the patient perceived the severity. In some cases, the patient is told a medical procedure is the only option to resolve the diagnosis. However, current research does not support subacromial decompression surgery or rotator cuff repairs, as neither is superior to sham or non-surgical management.
So, is it the label itself that is harmful, or the resulting treatments? If patients are provided advice to remain active and given a positive prognosis (as is supported by the evidence for low back pain, knee Oa, and shoulder pain), will the label be harmful? Could it potentially provide reassurance or validation, like with imaging? This study examined the effects of diagnostic labels and advice.
The study included 2039 participants with non-traumatic shoulder pain. The participants read a clinical vignette of a person with 6 months of shoulder pain and were asked to imagine being that person. They were randomized into 1 or 4 groups: bursitis label plus guideline-based advice, bursitis label plus treatment recommendation, rotator cuff tear label plus guideline-based advice, and rotator cuff tear label plus treatment recommendation.
Here was the verbiage for the guideline-based advice: ‘I am not worried that there is anything serious going on here because your pain is not related to a significant injury. I am also not worried that you have arthritis in your shoulder or a specific condition called frozen shoulder that causes severe pain and stiffness. Your pain should gradually improve over time by itself. It is recommended that you avoid activities that aggravate your pain but continue to use your arm so your shoulder does not stiffen up.’ This was the treatment recommendation verbiage: ‘Most people with your symptoms respond to treatment within 4 to 6 weeks, especially if an injection is part of the treatment. Without proper treatment, your symptoms can persist for months or years, and usually become worse over time.’
The researchers then assessed the interactions between labels and advice on the perceived need for shoulder surgery in people with rotator cuff disease. Secondary outcomes included a perceived need for imaging, an injection, a second opinion, and to see a specialist; and perceived seriousness of the condition, recovery expectations, impact on work performance, and need to avoid work.
All of the outcome scales were 0-10. Bursitis labeling and guideline-based advice had small but significant improvements in the perceived need for surgery (0.5 1.0) and imaging (0.6, 1.4). Guidelines-based advice reduced the perceived need for surgery (1.0), surgery (1.4), injection (3.4), and a specialist (1.4). Guideline advice also reduced the perceived seriousness of the condition (1.9). All other outcomes for guideline-based advice and every outcome for bursitis lead to less than 1/10 improvement or no change.
The results suggest that guidelines-based advice that promotes physical activity, and a positive prognosis should accompany diagnostic labels and pathology discussions. Bursitis may be a better label than rotator cuff tear, but these are differing pathologies. You may elect to use the more general ‘subacromial pain’ to potentially reduce concerns.
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