Continues discourse about “level V evidence”

In my recent post I discussed about “Level V Guideline” for subacromial decompression. I naturally participated to the discussion Drs Poolman and van den Bekerom had started. We wrote in our letter:

‘Optimal patient selection’ can be considered a myth until evidence of effect modifiers arises. We argue that if there were subpopulations that benefit from these procedures, we would have already identified them after 4 decades of using modern arthroscopy. It is simply not plausible that a meaningful effect keeps hiding because no one is able to define optimal inclusion criteria for efficacy studies.

As Poolman and van den Bekerom said, “burden of proof lies with those who claim that SAD is effective”. No such evidence exist so it is relevant to ask where does the evidence keeps hiding.

We summarized our criticism as follows:

It may be time for a paradigm shift: Embrace the natural course and accept degeneration until effective treatments arise.

We got a response to our letter which is of course nice, but also frustrating because this debate is circular. Original authors responded:

SAD for impingent remains a controversial topic, and it appears that many of us are strongly opinionated. This certainly reflects the lack of agreement but also the lack of strong and reliable evidence. It may not be time for a paradigm shift but time to create this evidence. Given the difficulties of designing a watertight randomized trial and including most of the potential confounders, this may not be possible in the near future.

(Emphasis added)

All I can say is that OK then.

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