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Parker A, Arundel C, Clark L, Coleman E, Doherty L, Hewitt CE, Beard D, Bower P, Cooper C, Culliford L, Devane D, Emsley R, Eldridge S, Galvin S, Gillies K, Montgomery A, Sutton CJ, Treweek S, Torgerson DJ. Undertaking Studies Within A Trial to evaluate recruitment and retention strategies for randomised controlled trials: lessons learnt from the PROMETHEUS research programme. Health Technol Assess 2024; 28:1-114. [PMID: 38327177 PMCID: PMC11017159 DOI: 10.3310/htqw3107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
Background Randomised controlled trials ('trials') are susceptible to poor participant recruitment and retention. Studies Within A Trial are the strongest methods for testing the effectiveness of strategies to improve recruitment and retention. However, relatively few of these have been conducted. Objectives PROMoting THE Use of Studies Within A Trial aimed to facilitate at least 25 Studies Within A Trial evaluating recruitment or retention strategies. We share our experience of delivering the PROMoting THE Use of Studies Within A Trial programme, and the lessons learnt for undertaking randomised Studies Within A Trial. Design A network of 10 Clinical Trials Units and 1 primary care research centre committed to conducting randomised controlled Studies Within A Trial of recruitment and/or retention strategies was established. Promising recruitment and retention strategies were identified from various sources including Cochrane systematic reviews, the Study Within A Trial Repository, and existing prioritisation exercises, which were reviewed by patient and public members to create an initial priority list of seven recruitment and eight retention interventions. Host trial teams could apply for funding and receive support from the PROMoting THE Use of Studies Within A Trial team to undertake Studies Within A Trial. We also tested the feasibility of undertaking co-ordinated Studies Within A Trial, across multiple host trials simultaneously. Setting Clinical trials unit-based trials recruiting or following up participants in any setting in the United Kingdom were eligible. Participants Clinical trials unit-based teams undertaking trials in any clinical context in the United Kingdom. Interventions Funding of up to £5000 and support from the PROMoting THE Use of Studies Within A Trial team to design, implement and report Studies Within A Trial. Main outcome measures Number of host trials funded. Results Forty-two Studies Within A Trial were funded (31 host trials), across 12 Clinical Trials Units. The mean cost of a Study Within A Trial was £3535. Twelve Studies Within A Trial tested the same strategy across multiple host trials using a co-ordinated Study Within A Trial design, and four used a factorial design. Two recruitment and five retention strategies were evaluated in more than one host trial. PROMoting THE Use of Studies Within A Trial will add 18% more Studies Within A Trial to the Cochrane systematic review of recruitment strategies, and 79% more Studies Within A Trial to the Cochrane review of retention strategies. For retention, we found that pre-notifying participants by card, letter or e-mail before sending questionnaires was effective, as was the use of pens, and sending personalised text messages to improve questionnaire response. We highlight key lessons learnt to guide others planning Studies Within A Trial, including involving patient and public involvement partners; prioritising and selecting strategies to evaluate and elements to consider when designing a Study Within A Trial; obtaining governance approvals; implementing Studies Within A Trial, including individual and co-ordinated Studies Within A Trials; and reporting Study Within A Trials. Limitations The COVID-19 pandemic negatively impacted five Studies Within A Trial, being either delayed (n = 2) or prematurely terminated (n = 3). Conclusions PROMoting THE Use of Studies Within A Trial significantly increased the evidence base for recruitment and retention strategies. When provided with both funding and practical support, host trial teams successfully implemented Studies Within A Trial. Future work Future research should identify and target gaps in the evidence base, including widening Study Within A Trial uptake, undertaking more complex Studies Within A Trial and translating Study Within A Trial evidence into practice. Study registration All Studies Within A Trial in the PROMoting THE Use of Studies Within A Trial programme had to be registered with the Northern Ireland Network for Trials Methodology Research Study Within A Trial Repository. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/55/80) and is published in full in Health Technology Assessment; Vol. 28, No. 2. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Adwoa Parker
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Catherine Arundel
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Laura Clark
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Elizabeth Coleman
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Laura Doherty
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Science, NIHR Biomedical Research Unit, University of Oxford, Oxford, UK
| | - Peter Bower
- National Institute for Health Research School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Cindy Cooper
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Lucy Culliford
- Bristol Trials Centre, Clinical Trials and Evaluation Unit, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Declan Devane
- School of Nursing and Midwifery, University of Galway, Galway, Republic of Ireland
- Health Research Board-Trials Methodology Research Network, Galway, Republic of Ireland
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sandra Eldridge
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Sandra Galvin
- School of Nursing and Midwifery, University of Galway, Galway, Republic of Ireland
- Health Research Board-Trials Methodology Research Network, Galway, Republic of Ireland
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Foresthill, Aberdeen, UK
| | - Alan Montgomery
- University of Nottingham, Nottingham Clinical Trials Unit, University Park Nottingham, Nottinghamshire, UK
| | | | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Foresthill, Aberdeen, UK
| | - David J Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
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Littlewood C, Moffatt M, Beckhelling J, Davis D, Burden A, Pitt L, Lalande S, Maddocks C, Stephens G, Tunnicliffe H, Pawson J, Lloyd J, Manca A, Wade J, Foster NE. Physiotherapist-led exercise versus usual care (waiting-list) control for patients awaiting rotator cuff repair surgery: A pilot randomised controlled trial (POWER). Musculoskelet Sci Pract 2023; 68:102874. [PMID: 37926065 DOI: 10.1016/j.msksp.2023.102874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Once a decision to undergo rotator cuff repair surgery is made, patients are placed on the waiting list. It can take weeks or months to receive surgery. There has been a call to move from waiting lists to 'preparation' lists to better prepare patients for surgery and to ensure it remains an appropriate treatment option for them. OBJECTIVE To evaluate the feasibility, as measured by recruitment rates, treatment fidelity and follow-up rates, of a future multi-centre randomised controlled trial to compare the clinical and cost-effectiveness of undertaking a physiotherapist-led exercise programme while waiting for surgery versus usual care (waiting-list control). DESIGN Two-arm, multi-centre pilot randomised controlled trial with feasibility objectives in six NHS hospitals in England. METHOD Adults (n = 76) awaiting rotator cuff repair surgery were recruited and randomly allocated to a programme of physiotherapist-led exercise (n = 38) or usual care control (n = 38). RESULTS Of 302 eligible patients, 76 (25%) were randomised. Of 38 participants randomised to physiotherapist-led exercise, 28 (74%) received the exercise programme as intended. 51/76 (67%) Shoulder Pain and Disability Index questionnaires were returned at 6-months. Of 76 participants, 32 had not received surgery after 6-months (42%). Of those 32, 20 were allocated to physiotherapist-led exercise; 12 to usual care control. CONCLUSIONS A future multi-centre randomised controlled trial is feasible but would require planning for variable recruitment rates between sites, measures to improve treatment fidelity and opportunity for surgical exit, and optimisation of follow-up. A fully powered, randomised controlled trial is now needed to robustly inform clinical decision-making.
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Affiliation(s)
- Chris Littlewood
- Faculty of Health, Social Care & Medicine, Edge Hill University, St Helen's Road, Ormskirk, Lancashire, L39 4QP, UK.
| | - Maria Moffatt
- Faculty of Health, Social Care & Medicine, Edge Hill University, St Helen's Road, Ormskirk, Lancashire, L39 4QP, UK
| | - Jacqueline Beckhelling
- Derby Clinical Trials Support Unit, University Hospitals Derby & Burton NHS Foundation Trust, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - Daniel Davis
- Derby Clinical Trials Support Unit, University Hospitals Derby & Burton NHS Foundation Trust, Royal Derby Hospital, Derby, DE22 3NE, UK
| | | | - Lisa Pitt
- University Hospitals Derby & Burton NHS Foundation Trust, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - Stacey Lalande
- Airedale NHS Foundation Trust, Airedale General Hospital, Skipton Rd, Steeton, Keighley, BD20 6TD, UK
| | - Catrin Maddocks
- Robert Jones & Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - Gareth Stephens
- The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK
| | - Helen Tunnicliffe
- University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, LE1 5WW, UK
| | - Jessica Pawson
- Barts Health NHS Trust, Royal London Hospital, Whitechapel, E1 1FR, UK
| | - James Lloyd
- Barts Health NHS Trust, Royal London Hospital, Whitechapel, E1 1FR, UK
| | - Andrea Manca
- Centre for Health Economics, University of York, York, YO10 5DD, UK
| | - Julia Wade
- Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Nadine E Foster
- STARS Education and Research Alliance, Surgical, Treatment and Rehabilitation Service (STARS), The University of Queensland and Metro North Health, Queensland, QLD 4029, Australia
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Puzzitiello RN, Patel BH, Lavoie-Gagne O, Lu Y, Nwachukwu BU, Forsythe B, Salzler MJ. Corticosteroid Injections After Rotator Cuff Repair Improve Function, Reduce Pain, and Are Safe: A Systematic Review. Arthrosc Sports Med Rehabil 2022; 4:e763-e774. [PMID: 35494258 PMCID: PMC9042756 DOI: 10.1016/j.asmr.2021.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 10/11/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose To review the literature on postoperative corticosteroid injections (CSIs) following primary rotator cuff repair (RCR) to evaluate efficacy and adverse effects. Methods A systematic review of the MEDLINE, EMBASE, and Cochrane databases were performed to identify all studies published within the last 15 years, which reported on outcomes of postoperative CSIs following RCR. Studies including patients who received only preoperative CSIs and revision RCRs were excluded. Included studies were evaluated for study methodology, patient demographics, outcome measures, physical examination parameters, results of imaging studies, and adverse effects or clinical complications. Results Seven studies comprising 5,528 patients satisfied inclusion criteria. Among included patients, 54.8% were female and mean age range from 52.3 ± 13.0 to 62.7 ± 6.6 years. Only 1 included investigation was a Level I study. Overall, 4 of 5 studies reported significant improvements in pain and outcome scores (Constant score, American Shoulder and Elbow Surgeons score) compared with controls. Across all studies, the majority of these effects were statistically significant at 3 months postoperatively but not beyond this time point. Five of the 6 included investigations reported no increased rate of retears after postoperative CSIs. One study did find an increase in retear in patients receiving postoperative CSIs but was unable to determine whether these retears were present before the patient received the CSI. Another investigation reported an increased rate of infection only if the CSI was administered in the first postoperative month. Conclusions Postoperative CSIs may improve pain and function for up to 3 months following primary RCR but not at later follow-up time points. CSIs should be administered only after the first postoperative month to minimize the potential risk for adverse events. Level of Evidence Systematic review of level I-IV studies.
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Bourke J, Skouteris H, Hatzikiriakidis K, Fahey D, Malliaras P. Use of Behavior Change Techniques Alongside Exercise in the Management of Rotator Cuff-Related Shoulder Pain: A Scoping Review. Phys Ther 2022; 102:6482025. [PMID: 34972867 DOI: 10.1093/ptj/pzab290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 08/20/2021] [Accepted: 11/19/2021] [Indexed: 02/09/2023]
Abstract
OBJECTIVES The aims of this scoping review were to: (1) determine the frequency and types of behavior change techniques (BCTs) and education utilized in trials investigating exercise interventions for rotator cuff related shoulder pain (RCRSP); (2) subcategorize the BCTs and education found in the trials to summarize all behavior change approaches reported by trials; and (3) compare the frequency, types, and subcategories of BCTs and education utilized in the clinical guidelines for managing RCRSP between the trials. METHODS Data sources included Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE, CINAHL Plus, Google Scholar and PubMed, which were searched from inception to June 2020. Trials assessing exercise interventions for RCRSP were included. Three authors independently determined eligibility and extracted data. The frequency and types of BCTs and education in the trials and clinical practice guidelines were reported and compared descriptively. Two authors assessed the content of the BCTs to develop subcategories. RESULTS Most trials reported including at least 1 type of BCT (89.2%), which was most commonly feedback and monitoring (78.5%). There were many different approaches to the BCTs and education; for example, feedback and monitoring was subcategorized into supervised exercise, exercise monitoring, and feedback through external aids, such as mirrors. Clinical guidelines recommend supervision, goal setting, activity modification, pain management recommendations, information about the condition, and exercise education. CONCLUSION Although over two-thirds of trials reported including a BCT alongside exercise interventions for RCRSP, the breadth of these interventions is limited (supervision is the only common one). Future trialists should consider using any type of BCT that may improve exercise adherence and outcomes. IMPACT The findings of this review have: (1) identified gaps in the literature; and (2) contributed to the design of future exercise interventions for RCRSP.
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Affiliation(s)
- Jaryd Bourke
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Victoria, Australia
| | - Helen Skouteris
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Kostas Hatzikiriakidis
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - David Fahey
- Enhance Sports Performance and Rehabilitation, Maribyrnong, Victoria, Australia
| | - Peter Malliaras
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Victoria, Australia
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Hopewell S, Keene DJ, Heine P, Marian IR, Dritsaki M, Cureton L, Dutton SJ, Dakin H, Carr A, Hamilton W, Hansen Z, Jaggi A, Littlewood C, Barker K, Gray A, Lamb SE. Progressive exercise compared with best-practice advice, with or without corticosteroid injection, for rotator cuff disorders: the GRASP factorial RCT. Health Technol Assess 2021; 25:1-158. [PMID: 34382931 PMCID: PMC9421560 DOI: 10.3310/hta25480] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Rotator cuff-related shoulder pain is very common, but there is uncertainty regarding which modes of exercise delivery are optimal and the long-term benefits of corticosteroid injections. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of progressive exercise compared with best-practice physiotherapy advice, with or without corticosteroid injection, in adults with a rotator cuff disorder. DESIGN This was a pragmatic multicentre superiority randomised controlled trial (with a 2 × 2 factorial design). SETTING Twenty NHS primary care-based musculoskeletal and related physiotherapy services. PARTICIPANTS Adults aged ≥ 18 years with a new episode of rotator cuff-related shoulder pain in the previous 6 months. INTERVENTIONS A total of 708 participants were randomised (March 2017-May 2019) by a centralised computer-generated 1 : 1 : 1 : 1 allocation ratio to one of four interventions: (1) progressive exercise (n = 174) (six or fewer physiotherapy sessions), (2) best-practice advice (n = 174) (one physiotherapy session), (3) corticosteroid injection then progressive exercise (n = 182) (six or fewer physiotherapy sessions) or (4) corticosteroid injection then best-practice advice (n = 178) (one physiotherapy session). MAIN OUTCOME MEASURES The primary outcome was Shoulder Pain and Disability Index (SPADI) score over 12 months. Secondary outcomes included SPADI subdomains, the EuroQol 5 Dimensions, five-level version, sleep disturbance, fear avoidance, pain self-efficacy, return to activity, Global Impression of Treatment and health resource use. Outcomes were collected by postal questionnaires at 8 weeks and at 6 and 12 months. A within-trial economic evaluation was also conducted. The primary analysis was intention to treat. RESULTS Participants had a mean age of 55.5 (standard deviation 13.1) years and 49.3% were female. The mean baseline SPADI score was 54.1 (standard deviation 18.5). Follow-up rates were 91% at 8 weeks and 87% at 6 and 12 months. There was an overall improvement in SPADI score from baseline in each group over time. Over 12 months, there was no evidence of a difference in the SPADI scores between the progressive exercise intervention and the best-practice advice intervention in shoulder pain and function (adjusted mean difference between groups over 12 months -0.66, 99% confidence interval -4.52 to 3.20). There was also no difference in SPADI scores between the progressive exercise intervention and best-practice advice intervention when analysed at the 8-week and 6- and 12-month time points. Injection resulted in improvement in shoulder pain and function at 8 weeks compared with no injection (adjusted mean difference -5.64, 99% confidence interval -9.93 to -1.35), but not when analysed over 12 months (adjusted mean difference -1.11, 99% confidence interval -4.47 to 2.26), or at 6 and 12 months. There were no serious adverse events. In the base-case analysis, adding injection to best-practice advice gained 0.021 quality-adjusted life-years (p = 0.184) and increased the cost by £10 per participant (p = 0.747). Progressive exercise alone was £52 (p = 0.247) more expensive per participant than best-practice advice, and gained 0.019 QALYs (p = 0.220). At a ceiling ratio of £20,000 per quality-adjusted life-year, injection plus best-practice advice had a 54.93% probability of being the most cost-effective treatment. LIMITATIONS Participants and physiotherapists were not blinded to group allocation. Twelve-month follow-up may be insufficient for identifying all safety concerns. CONCLUSIONS Progressive exercise was not superior to a best-practice advice session with a physiotherapist. Subacromial corticosteroid injection improved shoulder pain and function, but provided only modest short-term benefit. Best-practice advice in combination with corticosteroid injection was expected to be most cost-effective, although there was substantial uncertainty. FUTURE WORK Longer-term follow-up, including any serious adverse effects of corticosteroid injection. TRIAL REGISTRATION Current Controlled Trials ISRCTN16539266 and EudraCT 2016-002991-28. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 48. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Sally Hopewell
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David J Keene
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Peter Heine
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ioana R Marian
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lucy Cureton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Helen Dakin
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Willie Hamilton
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Zara Hansen
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Anju Jaggi
- Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK
| | | | - Karen Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alastair Gray
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
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Hopewell S, Keene DJ, Marian IR, Dritsaki M, Heine P, Cureton L, Dutton SJ, Dakin H, Carr A, Hamilton W, Hansen Z, Jaggi A, Littlewood C, Barker KL, Gray A, Lamb SE. Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): a multicentre, pragmatic, 2 × 2 factorial, randomised controlled trial. Lancet 2021; 398:416-428. [PMID: 34265255 PMCID: PMC8343092 DOI: 10.1016/s0140-6736(21)00846-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/25/2021] [Accepted: 04/01/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Corticosteroid injections and physiotherapy exercise programmes are commonly used to treat rotator cuff disorders but the treatments' effectiveness is uncertain. We aimed to compare the clinical effectiveness and cost-effectiveness of a progressive exercise programme with a single session of best practice physiotherapy advice, with or without corticosteroid injection, in adults with a rotator cuff disorder. METHODS In this pragmatic, multicentre, superiority, randomised controlled trial (2 × 2 factorial), we recruited patients from 20 UK National Health Service trusts. We included patients aged 18 years or older with a rotator cuff disorder (new episode within the past 6 months). Patients were excluded if they had a history of significant shoulder trauma (eg, dislocation, fracture, or full-thickness tear requiring surgery), neurological disease affecting the shoulder, other shoulder conditions (eg, inflammatory arthritis, frozen shoulder, or glenohumeral joint instability), received corticosteroid injection or physiotherapy for shoulder pain in the past 6 months, or were being considered for surgery. Patients were randomly assigned (centralised computer-generated system, 1:1:1:1) to progressive exercise (≤6 sessions), best practice advice (one session), corticosteroid injection then progressive exercise, or corticosteroid injection then best practice advice. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score over 12 months, analysed on an intention-to-treat basis (statistical significance set at 1%). The trial was registered with the International Standard Randomised Controlled Trial Register, ISRCTN16539266, and EuDRACT, 2016-002991-28. FINDINGS Between March 10, 2017, and May 2, 2019, we screened 2287 patients. 708 patients were randomly assigned to progressive exercise (n=174), best practice advice (n=174), corticosteroid injection then progressive exercise (n=182), or corticosteroid injection then best practice advice (n=178). Over 12 months, SPADI data were available for 166 (95%) patients in the progressive exercise group, 164 (94%) in the best practice advice group, 177 (97%) in the corticosteroid injection then progressive exercise group, and 175 (98%) in the corticosteroid injection then best practice advice group. We found no evidence of a difference in SPADI score between progressive exercise and best practice advice when analysed over 12 months (adjusted mean difference -0·66 [99% CI -4·52 to 3·20]). We also found no evidence of a difference between corticosteroid injection compared with no injection when analysed over 12 months (-1·11 [-4·47 to 2·26]). No serious adverse events were reported. INTERPRETATION Progressive exercise was not superior to a best practice advice session with a physiotherapist in improving shoulder pain and function. Subacromial corticosteroid injection provided no long-term benefit in patients with rotator cuff disorders. FUNDING UK National Institute for Health Research Technology Assessment Programme.
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Affiliation(s)
- Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - David J Keene
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ioana R Marian
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Peter Heine
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lucy Cureton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Helen Dakin
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Willie Hamilton
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Zara Hansen
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Anju Jaggi
- Royal National Orthopaedic Hospital NHS Trust, Stanmore, Middlesex, UK
| | - Chris Littlewood
- Department of Health Professions, Manchester Metropolitan University, Manchester, UK
| | - Karen L Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alastair Gray
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; College of Medicine and Health, University of Exeter, Exeter, UK
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Cureton L, Marian IR, Barber VS, Parker A, Torgerson DJ, Hopewell S. Randomised study within a trial (SWAT) to evaluate personalised versus standard text message prompts for increasing trial participant response to postal questionnaires (PROMPTS). Trials 2021; 22:502. [PMID: 34321055 PMCID: PMC8320189 DOI: 10.1186/s13063-021-05452-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 07/13/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Use of a person's name in a text message has been shown to be effective in instigating behaviour change. We evaluated the effectiveness of a personalised text message (including the recipient's name) versus a standardised text message for prompting a response from trial participants to complete and return postal follow-up questionnaires. METHODS Using a randomised study within a trial (SWAT) embedded within the host GRASP (Getting it Right: Addressing Shoulder Pain) trial, participants who provided a mobile telephone number were randomised (1:1) by a central computer system to receive either (1) a personalised text message which included their name or (2) a standard text message. Text messages were sent by the trial office on the same day as the 6-month GRASP follow-up questionnaire. The primary outcome was questionnaire response rate, defined as the proportion of 6-month GRASP follow-up questionnaires returned by participants. Secondary outcomes included time to response, the proportion of participants sent a reminder follow-up questionnaire, and cost. RESULTS Between March 2017 and May 2019 (recruitment period for GRASP trial), 618 participants were randomised to a personalised (n = 309) or standard (n = 309) text message and all were included in the analysis. The overall questionnaire response rate was 87% (n = 537/618); 90% (n = 277/309) of participants responded in the personalised text message group compared to 84% (n = 260/309) in the standard text message group (relative risk (RR) 1.07; 95% CI 1.00 to 1.13). Participants randomised to receive the personalised text message were more likely to return their initial postal questionnaire than those who received the standard text message (n = 185/309; 60% vs. n = 160/309; 52%) (RR 1.16; 95% CI 1.00 to 1.33); this represents an absolute percentage difference between intervention groups of 8%. Post hoc subgroup analysis showed that males under 65 years were the group most likely to return their initial questionnaire if they received a personalised text message. CONCLUSION Overall, participants who received a personalised text message were more likely to return their questionnaire than those who received the standard text message. TRIAL REGISTRATION GRASP Trial ISRCTN16539266 ; SWAT Repository ID 35.
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Affiliation(s)
- Lucy Cureton
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ioana R Marian
- Oxford Clinical Trials Research Unit/Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Building, Windmill Road, Oxford, OX3 7LD, UK
| | - Vicki S Barber
- Oxford Clinical Trials Research Unit/Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Building, Windmill Road, Oxford, OX3 7LD, UK
| | | | | | - Sally Hopewell
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
- Oxford Clinical Trials Research Unit/Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Building, Windmill Road, Oxford, OX3 7LD, UK.
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8
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Kazempour Mofrad M, Rezasoltani Z, Dadarkhah A, Kazempour Mofrad R, Abdorrazaghi F, Azizi S. Periarticular Neurofascial Dextrose Prolotherapy Versus Physiotherapy for the Treatment of Chronic Rotator Cuff Tendinopathy: Randomized Clinical Trial. J Clin Rheumatol 2021; 27:136-142. [PMID: 32975923 DOI: 10.1097/rhu.0000000000001218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE Rotator cuff tendinopathy is a common cause of shoulder pain. We aimed to compare periarticular (neurofascial) dextrose prolotherapy versus physiotherapy for treatment of chronic rotator cuff tendinopathy in the short term. METHODS We carried out a randomized clinical trial with 2 arms at a university hospital. In total, 66 patients with chronic rotator cuff tendinopathy, proven by magnetic resonance imaging, were randomly allocated to 2 groups. The outcomes were change in shoulder pain intensity (primary) and disability (secondary) index using a questionnaire for Shoulder Pain and Disability Index. For physiotherapy, participants received superficial heat, transcutaneous electrical nerve stimulation, and pulsed ultrasound. Also, they carried out an exercise program, 10 sessions of 30 minutes for 3 weeks. For prolotherapy, we used 8 mL of 12.5% dextrose and 40 mg of 2% lidocaine. The mixture was injected 2 times with 1-week interval superficially around the shoulder joint and to tender points along the suprascapular nerve. RESULTS Neurofascial dextrose was more effective than physiotherapy for alleviating pain in 2 weeks (p < 0.001), and they were similar 3 months after the interventions (p = 0.055). For disability, dextrose was more effective than physiotherapy 2 weeks and 3 months (both p < 0.001) after the interventions. However, the changes in the physiotherapy group seemed to be more sustained. CONCLUSIONS Both interventions are effective for the short-term management of rotator cuff tendinopathy. However, prolotherapy is more successful as the initial treatment. Besides, the treatment time is much shorter for dextrose prolotherapy compared with physiotherapy.
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Affiliation(s)
- Morteza Kazempour Mofrad
- From the Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Shahid Beheshti University of Medical Sciences
| | - Zahra Rezasoltani
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Aja University of Medical Sciences
| | - Afsaneh Dadarkhah
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Aja University of Medical Sciences
| | | | - Fateme Abdorrazaghi
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Aja University of Medical Sciences
| | - Sirous Azizi
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Aja University of Medical Sciences
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9
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Cook JA, Baldwin M, Cooper C, Nagra NS, Crocker JC, Glaze M, Greenall G, Rangan A, Kottam L, Rees JL, Farrar-Hockley D, Merritt N, Hopewell S, Beard D, Thomas M, Dritsaki M, Carr AJ. Patch augmentation surgery for rotator cuff repair: the PARCS mixed-methods feasibility study. Health Technol Assess 2021; 25:1-138. [PMID: 33646096 PMCID: PMC7958078 DOI: 10.3310/hta25130] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND A rotator cuff tear is a common, disabling shoulder problem. Symptoms may include pain, weakness, lack of shoulder mobility and sleep disturbance. Many patients require surgery to repair the tear; however, there is a high failure rate. There is a need to improve the outcome of rotator cuff surgery, and the use of patch augmentation (on-lay or bridging) to provide support to the healing process and improve patient outcomes holds promise. Patches have been made using different materials (e.g. human/animal skin or tissue and synthetic materials) and processes (e.g. woven or mesh). OBJECTIVES The aim of the Patch Augmented Rotator Cuff Surgery (PARCS) feasibility study was to determine the design of a definitive randomised controlled trial assessing the clinical effectiveness and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and feasible. DESIGN A mixed-methods feasibility study of a randomised controlled trial. DATA SOURCES MEDLINE, EMBASE and the Cochrane Library databases were searched between April 2006 and August 2018. METHODS The project involved six stages: a systematic review of clinical evidence, a survey of the British Elbow and Shoulder Society's surgical membership, a survey of surgeon triallists, focus groups and interviews with stakeholders, a two-round Delphi study administered via online questionnaires and a 2-day consensus meeting. The various stakeholders (including patients, surgeons and industry representatives) were involved in stages 2-6. RESULTS The systematic review comprised 52 studies; only 15 were comparative and, of these, 11 were observational (search conducted in August 2018). These studies were typically small (median number of participants 26, range 5-152 participants). There was some evidence to support the use of patches, although most comparative studies were at a serious risk of bias. Little to no published clinical evidence was available for a number of patches in clinical use. The membership survey of British Elbow and Shoulder surgeons [105 (21%) responses received] identified a variety of patches in use. Twenty-four surgeons (77%) completed the triallist survey relating to trial design. Four focus groups were conducted, involving 24 stakeholders. Differing views were held on a number of aspects of trial design, including the appropriate patient population (e.g. patient age) to participate. Agreement on the key research questions and the outline of two potential randomised controlled trials were achieved through the Delphi study [29 (67%)] and the consensus meeting that 22 participants attended. LIMITATIONS The main limitation was that the findings were influenced by the participants, who are not necessarily representative of the views of the relevant stakeholder groups. CONCLUSION The need for further clinical studies was clear, particularly given the range and number of different patches available. FUTURE WORK Randomised comparisons of on-lay patch use for completed rotator cuff repairs and bridging patch use for partial rotator cuff repairs were identified as areas for further research. The value of an observational study to assess safety concerns of patch use was also highlighted. These elements are included in the trial designs proposed in this study. STUDY REGISTRATION The systematic review is registered as PROSPERO CRD42017057908. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 13. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mathew Baldwin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Navraj S Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joanna C Crocker
- Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
| | - Molly Glaze
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Gemma Greenall
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amar Rangan
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Lucksy Kottam
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Jonathan L Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Dair Farrar-Hockley
- Patient representative, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Naomi Merritt
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Melina Dritsaki
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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10
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Malliaras P, Cridland K, Hopmans R, Ashton S, Littlewood C, Page R, Harris I, Skouteris H, Haines T. Internet and Telerehabilitation-Delivered Management of Rotator Cuff-Related Shoulder Pain (INTEL Trial): Randomized Controlled Pilot and Feasibility Trial. JMIR Mhealth Uhealth 2020; 8:e24311. [PMID: 33206059 PMCID: PMC7710452 DOI: 10.2196/24311] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/14/2020] [Accepted: 10/21/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Rotator cuff-related shoulder pain (RCRSP) is a common and disabling musculoskeletal condition. Internet-based and telerehabilitation delivery of recommended care may improve access to care and improve adherence and outcomes. OBJECTIVE The primary aim of this pilot randomized controlled trial was to assess the feasibility of a 12-week internet-delivered intervention for RCRSP comparing advice only, recommended care, and recommended care with group-based telerehabilitation. METHODS Reporting was in accordance with the Consolidated Standards of Reporting Trials (CONSORT) checklist for pilot and feasibility trials. People with a primary complaint of RCRSP for 3 months or longer were identified via a paid Facebook strategy. Screening involved an online questionnaire followed by a 20-minute telehealth assessment. Participants were randomly allocated (via a Zelen design) to receive (1) advice only, (2) recommended care (internet-delivered evidence-based exercise and education), or (3) recommended care and telerehabilitation (including a weekly group teleconference session). Progression criteria for a full-scale trial included (1) recruitment of 20% or greater of eligible participants, (2) acceptable adherence (two or more of the three prescribed weekly sessions) among 70% or greater of participants, (3) 80% or greater retention of participants, (4) absence of intervention-related serious adverse events, and (5) 80% or greater response rates to questionnaires. Secondary clinical and patient knowledge outcomes were collected (via email or text) at baseline, six weeks, and 12 weeks (for clinical and patient knowledge), and within-group change was reported descriptively. RESULTS We enrolled 36 of 38 (95%) eligible participants and all participants were recruited within a 3-week period. Of the 36 participants, 12 participants were allocated to each of the three trial arms. The mean age of participants was between 51 and 56 years, and 83% (10/12) to 92% (11/12) were female. Retention at the 12-week endpoint was 94% (34/36) and response to email questionnaires at other time points was 83% or greater. We found acceptable adherence (defined as greater than 70% of participants performing exercise 2 or 3 times/week) in the recommended care group with telerehabilitation but not in the recommended care group without telerehabilitation. There was a total of 24 adverse events over 108 person-months of observation. All adverse events were mild or moderate (mainly muscle and shoulder symptoms), with the exception of one instance of elective surgery (unrelated to the person's shoulder condition). CONCLUSIONS Our prespecified success criteria were met or exceeded, but there was a gender imbalance toward women. It is feasible to progress to a fully powered trial, but strategies to address the gender imbalance need to be implemented. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ACTRN12620000248965); https://tinyurl.com/yy6eztf5.
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Affiliation(s)
- Peter Malliaras
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - Kate Cridland
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - Ruben Hopmans
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - Simon Ashton
- Physiotherapy Department, School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - Chris Littlewood
- Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, United Kingdom
| | - Richard Page
- Barwon Orthopaedic Research and Education, Barwon Health and School of Medicine, Deakin University, Geelong, Australia
| | - Ian Harris
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.,Liverpool Hospital, Sydney, Australia
| | - Helen Skouteris
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Terry Haines
- School of Primary and Allied Health Care, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
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11
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Flemming J, Chojecki D, Tjosvold L, Paulden M, Armijo-Olivo S. Quality of reporting of economic evaluations in rehabilitation research: a systematic review. Disabil Rehabil 2020; 44:2233-2240. [PMID: 33126829 DOI: 10.1080/09638288.2020.1830441] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The quality of reporting of health economic evaluations for rehabilitation services has been questioned, limiting the ability to provide accurate recommendations for health decisions. PURPOSE To document current overall reporting quality of the published literature for economic evaluations of rehabilitation services using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), and to identify factors that could influence the quality of reporting. DATA SOURCES Electronic literature searches were performed using MEDLINE and the NHS Economic Evaluations Database via the Cochrane Library. STUDY SELECTION Prospective rehabilitation economic evaluation articles from 2013 to 2020 were selected. DATA EXTRACTION Data were extracted by one reviewer and independently verified by a second reviewer. DATA SYNTHESIS/RESULTS Title and abstracts of 3,454 papers were reviewed. 204 papers were selected for a full text screening. From those, 129 potential papers were identified to be included in this study. LIMITATIONS Only two databases were used in data collection, and papers were selected from 2013 to 2020 only. CONCLUSIONS Inconsistent reporting in health economic evaluations of rehabilitation services has continued, despite the availability of the CHEERS checklist. The methods of the analyzed studies were frequently under-reported, thereby creating challenges in determining whether the results reported were valid.IMPLICATIONS FOR REHABILITATIONVariable quality of reporting has been identified in rehabilitation research assessing cost-effectiveness.To grow as an area of expertise, the field of rehabilitation must produce research demonstrating its cost-effectiveness.Both rehabilitation clinicians and funders would benefit from full and transparent information to identify optimal solutions for effective and efficient care.
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Affiliation(s)
- Julie Flemming
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Dagmara Chojecki
- Institute of Health Economics (IHE), Edmonton, AB, Canada.,University of Alberta, Edmonton, AB, Canada
| | - Lisa Tjosvold
- Institute of Health Economics (IHE), Edmonton, AB, Canada.,University of Alberta, Edmonton, AB, Canada
| | - Mike Paulden
- School of Public Health, University of Alberta, Edmonton Clinic Health Academy, Edmonton, AB, Canada
| | - Susan Armijo-Olivo
- Faculty of Business and Social Sciences, University of Applied Sciences, Osnabrück, Germany.,Faculty of Rehabilitation Medicine, Corbett Hall, Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada.,Institute of Health Economics, Edmonton, AB, Canada
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12
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Amanollahi A, Asheghan M, Hashemi SE. Subacromial corticosteroid injection versus subcutaneous 5% dextrose in patients with chronic rotator cuff tendinopathy: A short-term randomized clinical trial. Interv Med Appl Sci 2020; 11:154-160. [PMID: 36343292 PMCID: PMC9467332 DOI: 10.1556/1646.11.2019.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/31/2019] [Accepted: 06/16/2019] [Indexed: 11/29/2022] Open
Abstract
Aim The aim of this study is to compare subcutaneous 5% dextrose versus subacromial corticosteroid injection for the treatment of chronic rotator cuff tendinopathy. Methods We carried out a randomized clinical trial with two parallel groups at a university hospital. Overall, 57 (32 women) were included in two groups of corticosteroid (n = 29) and dextrose (n = 28). The mean pain score was 6.6 (1.0). We used a visual analog scale for pain and goniometry for the range of motion. The measurements were repeated 1 month after the interventions. For corticosteroid, a single injection of triamcinolone and 1% lidocaine, and for dextrose, a mixture of 5% dextrose and 2% lidocaine three times weekly were prescribed. Results Both interventions were effective in decreasing pain compared to the baseline (both p < 0.001). The difference in pain between the two groups was nearly significant 1-month post-intervention (p = 0.052). The comparison of the two groups in considerable pain reduction (≥2.8) was in favor of dextrose (p = 0.046). The differences in the range of motion were not conclusive. None of the participants reported an important adverse effect. Conclusion The 5% dextrose treatment is at least as effective as corticosteroid for reducing pain in patients with rotator cuff tendinopathy.
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Affiliation(s)
- Asadollah Amanollahi
- 1 Department of Physical Medicine and Rehabilitation, School of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Mahsa Asheghan
- 2 Exercise Physiology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Seyed Ebrahim Hashemi
- 2 Exercise Physiology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Islamic Republic of Iran
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13
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Marian IR, Hopewell S, Keene DJ, Cureton L, Lamb SE, Dutton SJ. Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of rotator cuff disorders: statistical analysis plan for the Getting it Right: Addressing Shoulder Pain (GRASP) 2 × 2 factorial multicentre randomised controlled trial. Trials 2020; 21:767. [PMID: 32894159 PMCID: PMC7487843 DOI: 10.1186/s13063-020-04704-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Getting it Right: Addressing Shoulder Pain (GRASP) trial assesses the clinical and cost-effectiveness of individually tailored, progressive exercise compared with best practice advice, with or without corticosteroid injection, in adults with a rotator cuff disorder. This article describes the statistical analysis plan for the GRASP randomised controlled trial. METHODS/DESIGN GRASP is a multicentre randomised controlled trial using a 2 × 2 factorial design. Adults aged ≥ 18 years with a new episode of shoulder pain related to a rotator cuff disorder, not currently receiving physiotherapy or being considered for surgery, are randomised (centralised computer-generated 1:1:1:1 allocation ratio) to one of four interventions: (1) progressive exercise (up to 6 physiotherapy sessions), (2) best practice advice (one physiotherapy session), (3) subacromial corticosteroid injection then progressive exercise and (4) subacromial corticosteroid injection then best practice advice. The primary outcome is the mean difference in Shoulder Pain and Disability Index (SPADI) total score over 12 months. Secondary outcomes are as follows: pain and function SPADI subdomains, health-related quality of life (EuroQol EQ-5D-5L), sleep disturbance, return to activity, global impression of change, health resource use, out-of-pocket expenses and work disability. Here, we describe in detail the following: sample size calculation, descriptive statistics of the primary and secondary outcomes, statistical models used for the analysis of the main outcomes, handling of missing data, planned sensitivity and subgroup analyses. This pre-specified statistical analysis plan was written and submitted without prior knowledge of the trial results. DISCUSSION Publication of the statistical analysis plan for the GRASP trial aims to reduce the risk of outcome reporting bias and increase transparency of the data analysis. Any deviations or changes to the current SAP will be described and justified in the final study report and any results publications. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number ISRCTN16539266 . Registered on 14 June 2016. EudraCT number 2016-002991-28. Registered on 12 June 2016.
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Affiliation(s)
- Ioana R Marian
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Old Road, Oxford, OX3 7LD, UK.
| | - Sally Hopewell
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Old Road, Oxford, OX3 7LD, UK
| | - David J Keene
- Kadoorie Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences and Oxford NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Lucy Cureton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Old Road, Oxford, OX3 7LD, UK
| | - Sarah E Lamb
- Centre for Rehabilitation Research, Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,College of Medicine and Health, Institute for Health Research, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Old Road, Oxford, OX3 7LD, UK
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14
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Development of a physiotherapist-led exercise programme for traumatic tears of the rotator cuff for the SPeEDy study. Physiotherapy 2020; 111:66-73. [PMID: 33316867 DOI: 10.1016/j.physio.2020.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The SPeEDy study (Surgery vs. physiotherapist-led exercise for traumatic tears of the rotator cuff) is a two-arm, parallel group, pilot and feasibility randomised controlled trial aiming to evaluate the feasibility of a future main trial. In this paper, the development process and the resultant physiotherapist-led exercise programme used in the SPeEDy study is described. METHODS Thirteen physiotherapists and three patients met to discuss and develop the key principles that should underpin the exercise programme. RESULTS Taking in to account the current research evidence and incorporating expert clinical and patient opinion, the group developed an individualised, structured and progressive physiotherapist-led exercise programme based on the principle of self dosing. Exercise prescription within the programme is based on establishing the current functional capacity of the patient in relation to the most challenging shoulder movements and is supported over approximately six contact sessions across a 12-week period. CONCLUSION The SPeEDy study aims to recruit 76 participants across eight hospitals and will provide high quality evidence about the feasibility of a future main randomised controlled trial in a clinical area where there is a lack of evidence from randomised controlled trials to support clinical decision-making. ClinicalTrials.gov (NCT04027205) - Registered on 19 July 2019. Available via https://clinicaltrials.gov/ct2/show/NCT04027205.
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15
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Seven Key Themes in Physical Therapy Advice for Patients Living With Subacromial Shoulder Pain: A Scoping Review. J Orthop Sports Phys Ther 2020; 50:285-a12. [PMID: 32476583 DOI: 10.2519/jospt.2020.9152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To systematically scope the reported advice and education in physical therapy management of patients with subacromial shoulder pain, and to define key themes of the advice and education. DESIGN Scoping review. LITERATURE SEARCH We searched MEDLINE, Scopus, Web of Science, and CINAHL, with publication dates from 2007 to September 2019. STUDY SELECTION CRITERIA We included quantitative and qualitative research that reported on physical therapy interventions for subacromial shoulder pain. DATA SYNTHESIS We performed a qualitative synthesis that identified items included in patient advice and education. RESULTS Of 89 original studies included, there were 61 randomized controlled trials; 5 prospective studies; 16 nonrandomized observational intervention studies or case series; and 7 surveys, audits of physical therapy patient records, and focus groups with physical therapists. We identified 7 key themes for advice and education: exercise intensity and pain response, activity modification advice, posture advice, pain self-management advice, pathoanatomical and diagnosis information, behavioral approaches, and pain biology advice. CONCLUSION While advice focused predominantly on the local tissue pathology model, 10% of studies included information about pain neuroscience education, psychosocial factors, motor imagery, or behavior change. J Orthop Sports Phys Ther 2020;50(6):285-293. doi:10.2519/jospt.2020.9152.
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16
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Adverse Impact of Corticosteroids on Rotator Cuff Tendon Health and Repair: A Systematic Review of Basic Science Studies. Arthrosc Sports Med Rehabil 2020; 2:e161-e169. [PMID: 32368753 PMCID: PMC7190543 DOI: 10.1016/j.asmr.2020.01.002] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/13/2020] [Indexed: 11/22/2022] Open
Abstract
Purpose To evaluate the in vitro effects of corticosteroid injections (CSIs) on rotator cuff tendon (RCT). Methods A systematic review of the MEDLINE database was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for all studies reporting on adverse biochemical and biomechanical effects of CSIs on RCT. Results Sixteen studies were identified that had been published in the last 15 years on the effects of corticosteroids on RCTs. Eight of these studies were on human RCTs, 6 were on rat tendons, 1 considered both human and rat tendons, and 1 was on dog tendon. Five studies analyzed the effects of corticosteroids on the biomechanical properties of RCT or rotator cuff repair, whereas the remaining observed the cellular and molecular effects of CSIs on RCT. Corticosteroids suppress an inflammatory response, induce apoptosis, and have negative effects on collagen and tendon cell viability in RCTs. The mechanical properties, including load to failure of RCTs and rotator cuff repair anchor pull-out strength, also are decreased by CSIs. These in vitro effects appear to be transient as well as frequency and dose dependent. Conclusions On a molecular level, CSIs decrease cellular proliferation, alter collagen and extracellular matrix composition, impede inflammatory pathways, decrease cellular viability, increase adipocyte differentiation, and increase apoptosis. These changes can be seen as early as 24 hours after corticosteroid exposure, last as long as 2 to 3 weeks, and are exacerbated by increased doses and decreased latency between doses. Biomechanical studies demonstrate that these changes result in decreased maximal load to failure, tendon stiffness, and suture anchor pull-out strength in rat shoulders up to 2 weeks but not at 3 and 4 weeks, post-CSI. Clinical Relevance Shoulder subacromial steroid injection is common, and practitioners should be aware of results both positive and deleterious.
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Exploring the Business Case for Improving Quality of Care for Patients With Chronic Rotator Cuff Tears. Qual Manag Health Care 2019; 28:209-221. [PMID: 31567844 DOI: 10.1097/qmh.0000000000000231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Currently, management of patients presenting with chronic rotator cuff tears in Alberta is in need of quality improvements. This article explores the potential impact of a proposed care pathway whereby all patients presenting with chronic rotator cuff tears in Alberta would adopt an early, conservative management plan as the first stage of care; ultrasound investigation would be the preferred tool for diagnosing a rotator cuff tear; and only patients are referred for surgery once conservative measures have been exhausted. METHODS We evaluate evidence in support of surgery and conservative management, compare care in the current state with the proposed care pathway, and identify potential solutions in moving toward optimal care. RESULTS A literature search resulted in an absence of indications for either surgical or conservative management. Conservative management has the potential to reduce utilization of public health care resources and may be preferable to surgery. The proposed care pathway has the potential to avoid nearly Can $87 000 in public health care costs in the current system for every 100 patients treated successfully with conservative management. CONCLUSION The proposed care pathway is a low-cost, first-stage treatment that is cost-effective and has the potential to reduce unnecessary, costly surgical procedures.
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18
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Development and implementation of the physiotherapy-led exercise interventions for the treatment of rotator cuff disorders for the 'Getting it Right: Addressing Shoulder Pain' (GRASP) trial. Physiotherapy 2019; 107:252-266. [PMID: 32026827 DOI: 10.1016/j.physio.2019.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 07/04/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The Getting it Right: Addressing Shoulder Pain (GRASP) trial is a large-scale, multicentre, 2×2 factorial randomised controlled trial investigating clinical and cost-effectiveness of a progressive exercise programme versus best-practice advice, with or without corticosteroid injection, for treating people with rotator cuff disorders. Here we describe the development, implementation and details of the physiotherapy-led interventions. METHODS Medical Research Council guidance for developing complex interventions were used, taking into account clinical guidelines, expert and patient opinion, research evidence, current practice variation, and deliverability. A stakeholder meeting of 26 experts, clinicians, researchers, and patient representatives was used to design key components of the interventions. Stakeholders prioritised strengthening posterior rotator cuff muscles and using practical, easy-to-do exercises. The interventions were designed to be deliverable across the UK National Health Service. RESULTS Progressive exercise consists of up to six sessions with a physiotherapist over 16 weeks. The best-practice advice consists of one face-to-face session with a physiotherapist with substantially greater reliance on self-management. Both interventions include self-management advice, home-exercise instruction, and behaviour-change strategies to target exercise adherence. All participants receive a Participant Information Booklet. The best-practice advice intervention is a self-guided system of progressively challenging exercises, with demonstration videos and written materials. The progressive exercise intervention has a wider range of exercise options, and greater flexibility for tailoring, progression, supervised practice and feedback. CONCLUSION GRASP has recruited 708 participants and will provide high quality evidence to inform management of people with shoulder pain due to a rotator cuff disorder. Results are anticipated in 2020. TRIAL REGISTRATION NUMBER ISRCTN16539266; EudraCT number:2016-002991-28.
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Ribeiro DC, Abbott JH, Sharma S, Lamb SE. Process evaluation of complex interventions tested in randomised controlled trials in musculoskeletal disorders: a systematic review protocol. BMJ Open 2019; 9:e028160. [PMID: 31110107 PMCID: PMC6530329 DOI: 10.1136/bmjopen-2018-028160] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/27/2019] [Accepted: 04/05/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The effectiveness of complex interventions for the management of musculoskeletal disorders has been estimated in many randomised clinical trials (RCTs). These trials inform which interventions are the most effective, however they do not always inform how an intervention achieved its clinical outcomes, nor how and what elements of an intervention were delivered to patients. Such information is useful for translating findings into clinical practice. A few process evaluation studies have been conducted alongside RCTs and a variety of methods have been used. To gain a better understanding of current practices of process evaluation in RCTs in musculoskeletal disorders, this systematic review is designed to answer the following research question: How are process evaluation of complex interventions tested in RCTs in musculoskeletal disorders being conducted? METHODS AND ANALYSIS We will systematically search seven electronic databases (MEDLINE, SCOPUS, CINAHL, PsycINFO, EMBASE, Web of Science and Cochrane database) from the date of inception to August 2018 for studies on process evaluation of RCTs on non-surgical and non-pharmacological management of musculoskeletal disorders. We will include qualitative and quantitative studies conducted alongside RCTs, reported with the RCTs or separate studies that assessed interventions for musculoskeletal disorders. Two reviewers will screen abstracts and apply prespecified inclusion criteria to identify relevant studies, extract the data and assess the risk of bias within included studies. We will follow recommendations from the 'Cochrane Qualitative and Implementation Methods Group Guidance Series' when assessing methodological strengths and limitations of included studies. We will use a narrative synthesis to describe findings. ETHICS AND DISSEMINATION Ethical approval is not required as this review will not collect original data. Findings from this systematic review will be presented at a scientific conference and published in a peer reviewed journal. PROSPERO REGISTRATION NUMBER CRD42018109600.
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Affiliation(s)
- Daniel C Ribeiro
- School of Physiotherapy, University of Otago Division of Health Sciences, Dunedin, New Zealand
| | - J Haxby Abbott
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago Division of Health Sciences, Dunedin, New Zealand
| | - Saurab Sharma
- Department of Physiotherapy, Kathmandu University School of Medical Sciences, Dhulikhel, Bagmati, Nepal
- Orthopedic Surgery Section, Department of Surgical Sciences, University of Otago Dunedin School of Medicine, Dunedin, Otago, New Zealand
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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