Accuracy of placement of ultrasound-guided corticosteroid injection for subacromial pain (impingement) syndrome does not influence pain and function: Secondary analysis of a randomised controlled trial

OBJECTIVES

To investigate whether the accuracy of placement of ultrasound-guided (US-guided) corticosteroid injections for subacromial pain (impingement) syndrome (SAPS) influences pain and function outcomes.

METHODS

This was a secondary analysis of data collected in a previous randomised controlled trial (RCT). Video images of US-guided subacromial corticosteroid injections delivered in the RCT were reviewed to categorise injection accuracy into three groups: definitely/probably not in the subacromial bursa (Group 1); probably in the subacromial bursa (Group 2); and definitely in the subacromial bursa (Group 3). The primary outcome was the Shoulder Pain and Disability Index (SPADI) total score. Secondary outcomes included SPADI pain and function subscales and participants' self-reported global impression of change. Outcomes were compared between the accuracy groups after adjusting for pre-selected baseline characteristics.

RESULTS

US-guided injection accuracy data were available for 114 participants: 22 categorised into Group 1, 21 into Group 2 and 71 into Group 3. There were no significant differences in mean total SPADI scores between the three injection accuracy groups at 6 weeks (Group 2 vs. 1: 8.22 (95% CI -4.01, 20.50); Group 3 versus 1: -0.57 (95% CI -10.27, 9.13) or 6 months (Group 2 vs. 1: 12.38 (95% CI -5.34, 30.10); Group 3 versus 1: 3.10 (95% CI -11.04, 17.23).

CONCLUSIONS

The accuracy of injection placement in SAPS did not influence pain and function, suggesting that improvements in patients' outcomes using subacromial corticosteroid injections can be achieved without US guidance.

The cost-effectiveness of different approaches to exercise and corticosteroid injection for subacromial pain (impingement) syndrome

OBJECTIVES

To determine whether physiotherapist-led exercise intervention and US-guided subacromial CS injection is cost-effective when compared with standard advice and exercise leaflet and unguided injection in patients with subacromial pain (impingement) syndrome.

METHODS

An incremental cost-utility analysis using patient responses to the five-level EuroQoL-5D (EQ-5D-5L) questionnaire was undertaken from a healthcare perspective alongside a 2 × 2 factorial randomized trial with 256 participants over a 12-month follow-up period. Uncertainty was explored through the use of cost-effectiveness acceptability curves.

RESULTS

The cost-utility analysis indicated that physiotherapist-led exercise was associated with an incremental cost of £155.99 (95% CI 69.02, 241.93) and 0.031 (95% CI -0.01, 0.07) additional quality-adjusted life-years (QALYs), an incremental cost-effectiveness ratio (ICER) of £5031 per QALY gained and an 85% chance of being cost-effective at a threshold of £20 000 per QALY gained compared with the advice and exercise leaflet. US-guided injection was associated with an incremental cost of £15.89 (95% CI -59.36, 109.86) and 0.024 (95% CI -0.02, 0.07) additional QALYs, an ICER of £662 per QALY gained and a 83% chance of being cost-effective at a threshold of £20 000 per QALY gained compared with unguided injection.

CONCLUSION

Physiotherapist-led exercise was cost-effective compared with the advice and exercise leaflet, and US-guided injection was cost-effective when compared with unguided injection.

CLINICAL TRIAL REGISTRATION

ISRCTN, http://www.isrctn.com, ISRCTN42399123.

Optimising outcomes of exercise and corticosteroid injection in patients with subacromial pain (impingement) syndrome: a factorial randomised trial

Objectives

To compare the clinical effectiveness of (1) physiotherapist-led exercise versus an exercise leaflet, and (2) ultrasound-guided subacromial corticosteroid injection versus unguided injection for pain and function in subacromial pain (formerly impingement) syndrome (SAPS).

Methods

This was a single-blind 2×2 factorial randomised trial. Adults with SAPS were randomised equally to one of four treatment groups: (1) ultrasound-guided corticosteroid injection and physiotherapist-led exercise, (2) ultrasound-guided corticosteroid injection and an exercise leaflet, (3) unguided corticosteroid injection and physiotherapist-led exercise and (4) unguided corticosteroid injection and an exercise leaflet. The primary outcome was the Shoulder Pain and Disability Index (SPADI), collected at 6 weeks, 6 and 12 months and compared at 6 weeks for the injection interventions and 6 months for the exercise interventions by intention to treat.

Results

We recruited 256 participants (64 treatment per group). Response rates for the primary outcome were 94% at 6 weeks, 88% at 6 months and 80% at 12 months. Greater improvement in total SPADI score was seen with physiotherapist-led exercise than with the exercise leaflet at 6 months (adjusted mean difference −8.23; 95% CI −14.14 to -2.32). There were no significant differences between the injection groups at 6 weeks (−2.04; −7.29 to 3.22), 6 months (−2.36; −8.16 to 3.44) or 12 months (1.59; −5.54 to 8.72).

Conclusions

In patients with SAPS, physiotherapist-led exercise leads to greater improvements in pain and function than an exercise leaflet. Ultrasound guidance confers no additional benefit over unguided corticosteroid injection.

Trial registration number

ISRCTN42399123.

Providing patients with direct access to musculoskeletal physiotherapy: the impact on general practice musculoskeletal workload and resource use. The STEMS-2 study

Objectives

This study examined the real-world impact of patient direct access to NHS physiotherapy (self-referral) on (a) general practice consultations for musculoskeletal (MSK) conditions and (b) specified clinical management for patients with MSK conditions.

Design and setting

Natural experiment in four general practices and the associated physiotherapy service.

Methods

Anonymised routinely collected data were obtained. MSK coded GP consultations, recorded fit notes, MSK-related prescription medication, X-rays and MRI requests, and referrals to secondary care for patients consulting with MSK conditions were identified and trends described across a 6-year period (June 2011 to June 2017). Joinpoint regression analysis was used to identify any significant changes in GP MSK consultation trends before and after the introduction of self-referral to physiotherapy. Physiotherapy service data examined access methods used by patients (GP referred, GP recommended self-referral, true self-referral) and the number of physiotherapy sessions.

Results

Direct access resulted in inconsistent impact on general practices. In one arm of the experiment a significant increase in GP consultations was observed and in one arm was stable. Exploratory examination of clinical management showed only requests for X-rays (arm 1) and possibly requests for MRI (arm 2) changed over time. Physiotherapy service referrals showed a low uptake of true self-referral (10% and 6%) in each arm respectively.

Conclusion

This is the first study to examine the real-world impact of patient direct access to physiotherapy at general practice level. We found no consistent impact of patient direct access on GP MSK workload. Impact on some clinical management was observed but not consistently in the direction suggested by previous studies.

Determining One-Year Trajectories of Low-Back-Related Leg Pain in Primary Care Patients: Growth Mixture Modeling of a Prospective Cohort Study

OBJECTIVE

The clinical presentation and outcome of patients with back and leg pain in primary care are heterogeneous and may be better understood by identification of homogeneous and clinically meaningful subgroups. Subgroups of patients with different back pain trajectories have been identified, but little is known about the trajectories for patients with back-related leg pain. This study sought to identify distinct leg pain trajectories, and baseline characteristics associated with membership of each group, in primary care patients.

METHODS

Monthly data on leg pain intensity were collected over 12 months for 609 patients participating in a prospective cohort study of adult patients seeking health care for low-back and leg pain, including sciatica, of any duration and severity, from their general practitioner. Growth mixture modeling was used to identify clusters of patients with distinct leg pain trajectories. Trajectories were characterized using baseline demographic and clinical examination data. Multinomial logistic regression was used to predict latent class membership, with a range of covariates.

RESULTS

Four patient clusters were identified: improving mild pain (58%), persistent moderate pain (26%), persistent severe pain (13%), and improving severe pain (3%). Clusters showed statistically significant differences in a number of baseline characteristics.

CONCLUSION

Four trajectories of leg pain were identified. Clusters 1, 2, and 3 were generally comparable to back pain trajectories, while cluster 4, with major improvement in pain, is infrequently identified. Awareness of such distinct patient groups improves understanding of the course of leg pain and may provide a basis of classification for intervention.

Change in physical activity level and clinical outcomes in older adults with knee pain: a secondary analysis from a randomised controlled trial

Background

Exercise interventions improve clinical outcomes of pain and function in adults with knee pain due to osteoarthritis and higher levels of physical activity are associated with lower severity of pain and higher levels of physical functioning in older adults with knee osteoarthritis in cross-sectional studies. However, to date no studies have investigated if change in physical activity level during exercise interventions can explain clinical outcomes of pain and function. This study aimed to investigate if change in physical activity during exercise interventions is associated with future pain and physical function in older adults with knee pain.

Methods

Secondary longitudinal data analyses of a three armed exercise intervention randomised controlled trial. Participants were adults with knee pain attributed to osteoarthritis, over the age of 45 years old (n = 514) from Primary Care Services in the Midlands and Northwest regions of England.

Crude and adjusted associations between absolute change in physical activity from baseline to 3 months (measured by the self-report Physical Activity Scale for the Elderly (PASE)) and i) pain ii) physical function (Western Ontario and McMaster Universities Osteoarthritis Index) and iii) treatment response (OMERACT-OARSI responder criteria) at 3 and 6 months follow-up were investigated using linear and logistic regression.

Results

Change in physical activity level was not associated with future pain, function or treatment response outcomes in crude or adjusted models at 3 or 6 months (P > 0.05). A 10 point increase in PASE was not associated with pain β = − 0.01 (− 0.05, 0.02), physical function β = − 0.09 (− 0.19, 0.02) or likelihood (odds ratio) of treatment response 1.02 (0.99, 1.04) at 3 months adjusting for sociodemographics, clinical covariates and the trial intervention arm. Findings were similar for 6 month outcome models.

Conclusions

Change in physical activity did not explain future clinical outcomes of pain and function in this study. Other factors may be responsible for clinical improvements following exercise interventions. However, the PASE may not be sufficiently responsive to measure change in physical activity level. We also recommend further investigation into the responsiveness of commonly used physical activity measures.

Trial registration

(ISRCTN93634563). Registered 29th September 2011.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-1968-z) contains supplementary material, which is available to authorized users.

Relationship Between Attitudes and Beliefs and Physical Activity in Older Adults With Knee Pain: Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

To investigate how attitudes and beliefs about exercise relate to physical activity behavior in older adults with knee pain attributable to osteoarthritis (OA).

METHODS

We conducted secondary data analyses of a randomized controlled trial of exercise interventions (ISRCTN: 93634563). Participants were adults ≥45 years old with knee pain attributable to OA (n = 514). Crude and adjusted cross-sectional and longitudinal associations between baseline Self-Efficacy for Exercise (SEE), Positive Outcome Expectations for Exercise (POEE), Negative Outcome Expectations for Exercise scores, and physical activity level, at baseline, 3 months, and 6 months (measured by self-report using the Physical Activity Scale for the Elderly [PASE]), and important increases in physical activity level (from baseline to 6-month followup) were investigated using multiple linear and logistic regression.

RESULTS

Cross-sectional associations were found between SEE and PASE scores (β = 4.14 [95% confidence interval (95% CI) 0.26, 8.03]) and POEE and PASE scores (β = 16.71 [95% CI 1.87, 31.55]), adjusted for sociodemographic and clinical covariates. Longitudinal associations were found between baseline SEE and PASE scores at 3 months (β = 4.95 [95% CI 1.02, 8.87]) and 6 months β = 3.71 (0.26, 7.16), and baseline POEE and PASE at 3 months (β = 34.55 [95% CI 20.13, 48.97]) and 6 months (β = 25.74 [95% CI 11.99, 39.49]), adjusted for baseline PASE score and intervention arm. However, no significant associations with important increases in physical activity level were found.

CONCLUSION

Greater exercise self-efficacy and more positive exercise outcome expectations were associated with higher current and future physical activity levels. These may be targets for interventions aimed at increasing physical activity.

STEMS pilot trial: a pilot cluster randomised controlled trial to investigate the addition of patient direct access to physiotherapy to usual GP-led primary care for adults with musculoskeletal pain

INTRODUCTION

Around 17% of general practitioner (GP) consultations are for musculoskeletal conditions, which will rise as the population ages. Patient direct access to physiotherapy provides one solution, yet adoption in the National Health Service (NHS) has been slow.

SETTING

A pilot, pragmatic, non-inferiority, cluster randomised controlled trial (RCT) in general practice and physiotherapy services in the UK.

OBJECTIVES

Investigate feasibility of a main RCT.

PARTICIPANTS

Adult patients registered in participating practices and consulting with a musculoskeletal problem.

INTERVENTIONS

4 general practices (clusters) randomised to provide GP-led care as usual or the addition of a patient direct access to physiotherapy pathway.

OUTCOMES

Process outcomes and exploratory analyses of clinical and cost outcomes.

DATA COLLECTION

Participant-level data were collected via questionnaires at identification, 2, 6 and 12 months and through medical records.

BLINDING

The study statistician and research nurses were blinded to practice allocation.

RESULTS

Of 2696 patients invited to complete study questionnaires, 978 participated (intervention group n=425, control arm n=553) and were analysed. Participant recruitment was completed in 6 months. Follow-up rates were 78% (6 months) and 71% (12 months). No evidence of selection bias was observed. The direct access pathway was used by 90% of patients in intervention practices needing physiotherapy. Some increase in referrals to physiotherapy occurred from one practice, although waiting times for physiotherapy did not increase (28 days before, 26 days after introduction of direct access). No safety issues were identified. Clinical and cost outcomes were similar in both groups. Exploratory estimates of between group effect (using 36-item Short Form Health Survey (SF-36) Physical Component Summary (PCS)) at 6 months was -0.28 (95% CI -1.35 to 0.79) and at 12 months 0.12 (95% CI -1.27 to 1.51).

CONCLUSIONS

A full RCT is feasible and will provide trial evidence about the clinical and cost-effectiveness of patient direct access to physiotherapy.

TRIAL REGISTRATION NUMBER

ISRCTN23378642.

A pilot cluster randomised controlled trial to investigate the addition of direct access to physiotherapy to usual GP-led primary care for adults with musculoskeletal pain: the STEMS pilot trial protocol (ISRCTN23378642)

Background

Musculoskeletal problems are common, accounting for up to 30 % of general practitioner (GP) consultations and are a major cause of chronic disability worldwide. Demand for health care for musculoskeletal conditions is likely to continue to rise given the ageing population and the increasing impact of these common painful conditions. Physiotherapists are well equipped to deliver evidence-based management for these conditions. Direct access allows patients to access physiotherapy without seeing their GP or another referring practitioner first; however, for most patients in the UK, access to National Health Service physiotherapy is controlled through GP referral.

Methods/Design

The aim of this pilot, pragmatic, cluster trial is to assess the feasibility of a future large trial to compare the clinical and cost-effectiveness of the additional offer of direct access to physiotherapy versus continuing with usual GP-led primary care alone for adults with common musculoskeletal problems. The pilot will focus on process outcomes to assess feasibility, although performance of the likely outcomes of a main trial will also be assessed. This is a two-arm parallel, cluster RCT where GP practices are the units of randomisation (the clusters), yet data are collected from individual patients with musculoskeletal problems (the participants). A direct access service will be set up in the participating physiotherapy service to provide the option of direct access to patients of the intervention arm practices. Inclusion criteria are broad to reflect the ‘real-world’ operation of an NHS physiotherapy direct access service for patients with musculoskeletal pain. Data collection will be through patient self-reported questionnaires at baseline, 2, 6 and 12 months and medical record review.

Discussion

No previous trials have been conducted into direct access to physiotherapy for patients with musculoskeletal problems. The strengths of the STEMS pilot trial are its size, the length of follow-up, and collection of process, clinical and cost outcomes to fully inform a future main trial to meet calls to provide robust trial evidence of the impact on clinical outcomes, work loss and costs to provide clinicians and service funders with the high quality trial data they need to guide decisions on the best models of care.

Trial registration

The STEMS pilot trial is registered at Current Controlled Trials: ISRCTN23378642

Electronic supplementary material

The online version of this article (doi:10.1186/s40814-015-0020-4) contains supplementary material, which is available to authorized users.

Current management of pregnancy-related low back pain: a national cross-sectional survey of U.K. physiotherapists

BACKGROUND

Pregnancy-related low back pain (LBP) is very common. Evidence from a systematic review supports the use of exercise and acupuncture, although little is known about the care received by women with pregnancy-related back pain in the U.K.

OBJECTIVE

To describe current acupuncture and standard care management of pregnancy-related LBP by U.K. physiotherapists.

DESIGN

Cross-sectional survey of physiotherapists with experience of treating women with pregnancy-related LBP from three professional networks of the Chartered Society of Physiotherapy.

METHODS

In total, 1093 physiotherapists were mailed a questionnaire. The questionnaire captured respondents' demographic and practice setting information, and experience of managing women with pregnancy-related back pain, and investigated the reported management of pregnancy-related LBP using a patient case vignette of a specific, 'typical' case.

RESULTS

The overall response rate was 58% (629/1093). Four hundred and ninety-nine physiotherapists had experience of treating women with pregnancy-related LBP and were included in the analysis. Most respondents worked wholly or partly in the U.K. National Health Service (78%). Most respondents reported that they treat patients with pregnancy-related LBP in three to four one-to-one treatment sessions over 3 to 6 weeks. The results show that a range of management strategies are employed for pregnancy-related LBP, and multimodal management is common. The most common reported treatment was home exercises (94%), and 24% of physiotherapists reported that they would use acupuncture with the patient described in the vignette.

CONCLUSIONS

This study provides the first robust data on the management of pregnancy-related LBP by U.K. physiotherapists. Multimodal management is common, although exercise is the most frequently used treatment for pregnancy-related LBP. Acupuncture is used less often for this patient group.