[Show abstract][Hide abstract] ABSTRACT: Subacromial impingement syndrome is the most frequent cause of shoulder problems which themselves affect 1 in 3 adults. Management commonly includes exercise and corticosteroid injection. However, the few existing trials of exercise or corticosteroid injection for subacromial impingement syndrome are mostly small, of poor quality, and focus only on short-term results. Exercise packages tend to be standardised rather than individualised and progressed. There has been much recent interest in improving outcome from corticosteroid injections by using musculoskeletal ultrasound to guide injections. However, there are no high-quality trials comparing ultrasound-guided and blind corticosteroid injection in subacromial impingement syndrome. This trial will investigate how to optimise the outcome of subacromial impingement syndrome from exercise (standardised advice and information leaflet versus physiotherapist-led exercise) and from subacromial corticosteroid injection (blind versus ultrasound-guided), and provide long-term follow-up data on clinical and cost-effectiveness.Methods/design: The study design is a 2x2 factorial randomised controlled trial. 252 adults with subacromial impingement syndrome will be recruited from two musculoskeletal Clinical Assessment and Treatment Services at the primary-secondary care interface in Staffordshire, UK. Participants will be randomised on a 1:1:1:1 basis to one of four treatment groups: (1) ultrasound-guided subacromial corticosteroid injection and a physiotherapist-led exercise programme, (2) ultrasound-guided subacromial corticosteroid injection and an advice and exercise leaflet, (3) blind subacromial corticosteroid injection and a physiotherapist-led exercise programme, or (4) blind subacromial corticosteroid injection and an advice and exercise leaflet. The primary intention-to-treat analysis will be the mean differences in Shoulder Pain and Disability Index (SPADI) scores at 6 weeks for the comparison between injection interventions and at 6 months for the comparison between exercise interventions. Although independence of treatment effects is assumed, the magnitude of any interaction effect will be examined (but is not intended for the main analyses). Secondary outcomes will include comparison of long-term outcomes (12 months) and cost-effectiveness. A secondary per protocol analysis will also be performed.
This protocol paper presents detail of the rationale, design, methods and operational aspects of the SUPPORT trial.Trial registration: Current controlled trials ISRCTN42399123.
[Show abstract][Hide abstract] ABSTRACT: Management of musculoskeletal conditions in the UK is increasingly delivered in multidisciplinary clinical assessment and treatment services (CATS) at the primary-secondary care interface. However, there is little evidence concerning the characteristics and management of patients attending CATS.
To describe the characteristics, investigation, and treatment of adults attending a musculoskeletal CATS.
Cross-sectional analysis of cohort study baseline data from a musculoskeletal CATS in Stoke-on-Trent Primary Care Trust, UK.
All patients referred from primary care between February 2008 and June 2009 were mailed a pre-consultation questionnaire concerning pain duration, general health status, anxiety, depression, employment status, and work absence due to musculoskeletal problems. At the consultation, clinical diagnoses, body region(s) affected, investigations, and treatment were recorded.
A total of 2166 (73%) completed questionnaires were received. Chronic pain duration >1 year (55%), major physical limitation (76%), anxiety (49%), and depression (37%) were common. Of those currently employed, 516 (45%) had taken time off work in the last 6 months because of their musculoskeletal problem; 325 (29%) were unable to do their usual job. The most frequent investigations were X-rays (23%), magnetic resonance imaging (18%), and blood tests (14%): 1012 (48%) received no investigations. Injections were performed in 282 (13%) and 492 (23%) were referred to physiotherapy.
Although most patients presented with musculoskeletal problems suitable for CATS, chronic pain, physical limitation, anxiety, depression, and work disability were commonplace, highlighting the need for a biopsychosocial model of care that addresses psychological, social, and work-related needs, as well as pain and physical disability.
British Journal of General Practice 02/2013; 63(607):141-8. · 2.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To explore the perceptions and experiences of nurse and allied health professional consultants and key stakeholders.
Nurse and allied health professional consultants' roles were introduced in the United Kingdom in 1999 with defined role criteria and a remit to improve patient outcomes. Although these roles have now existed for over a decade, there is a lack of research as to whether these roles have achieved their intended impact on clinical care. Through an exploration of the experiences of consultant nurses and allied health professionals and key stakeholders who work with these practitioners, a greater understanding of the consultant role can be achieved.
A purposive sample of seven non-medical consultants (five nurses, one physiotherapist and a pharmacist) and eight stakeholders took part in focus group interviews. Each focus group was audio-taped and lasted between 1.5-2 hours. Content analysis was used to interpret the data.
Four main themes were identified: (1) Role interpretation--core features include clinical practice, leadership, education and research. Debate surrounded the need to incorporate managerial responsibilities into the role. (2) Role implementation required political skills and emotional intelligence. (3) Role impact especially on clinical practice was a major priority for both groups. (4) Challenges included lack of organisational and administrative support.
There was consensus amongst the two groups regarding the value of the role, key role functions and skills and the emerging impact on clinical practice.
Both groups were able to identify the clinical impact of the role including helping patients manage chronic pain, reducing the need for follow-up appointments and managing emergency admissions. To capture the clinical diversity of the roles, a variety of evaluation strategies should be implemented.
Journal of Clinical Nursing 02/2011; 20(3-4):537-44. · 1.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Recent healthcare policy has shifted the management of musculoskeletal conditions in the UK away from secondary care towards Clinical Assessment and Treatment Services at the primary-secondary care interface. However, little is known about the outcome of patients with musculoskeletal conditions referred from primary care to Clinical Assessment and Treatment Services or how best to identify those patients at high risk of poor outcome in this setting. We describe the protocol for a twelve-month prospective observational study which aims to describe the outcome of patients referred to musculoskeletal and back pain services at the primary-secondary care interface and to develop simple prognostic measures to guide clinical prioritisation and triage.
All patients referred over a twelve-month period from primary care to musculoskeletal and back pain clinics in the primary-secondary care interface Clinical Assessment and Treatment Service in North Staffordshire will be mailed a postal questionnaire prior to their consultation. This will collect information on quality of life, general health, anxiety and depression, pain, healthcare utilisation including medication use, occupational characteristics, and socio-demographics. At the consultation in the interface clinic, the clinical diagnosis, investigations requested, and clinical interventions will be recorded. Follow-up data for the twelve-month period subsequent to recruitment will be collected via mailed follow-up questionnaires at 6 and 12 months, and review of medical records.
This twelve-month prospective observational study of patients referred to a musculoskeletal Clinical Assessment and Treatment Service will assess the management and outcome of musculoskeletal care at the primary-secondary care interface as proposed in the Musculoskeletal Services Framework.
[Show abstract][Hide abstract] ABSTRACT: To develop a package of physiotherapy treatment for a randomized controlled trial in primary care for shoulder pain and audit its use within the trial.
A survey of current physiotherapy approaches to the management of shoulder pain was conducted. The most frequently reported treatments were proposed as a package of care for a physiotherapy intervention in a trial of shoulder pain. The package was refined by a subgroup of 13 physiotherapists. For patients receiving the physiotherapy intervention in the main trial (n = 98), the frequency of use of modalities over the treatment period was calculated by percentages of modality usage per number of patient contacts. Treatment details were recorded by the physiotherapist at each patient visit.
The physiotherapy intervention included passive movements/mobilizations, active movement/mobilizations, a home exercise programme, education and advice, and ultrasound. The most frequently used modality at the assessment visit was the standardized education and advice leaflet for shoulder pain (85%) followed by the home exercise programme (79%), which was reinforced throughout the trial treatment course. The most frequently used modalities over the treatment period were ultrasound (42%), active mobilizations (41%) and passive mobilizations (41%). The mean number of trial treatment visits was 6.2 (SD: 2.1; range 1-8). Additional trial treatments (1-8) were delivered to 12 patients. Eighty-five patients were given only one therapeutic diagnosis, and 13 were given two. The most common diagnoses were tendonitis (32%) and capsulitis (25%). Pain was the major problem in 78% of patients, 15% had stiffness and 7% of patients reported both pain and stiffness.
Physiotherapists complied well with the trial protocol. Few treatments were used in isolation. This report demonstrates how physiotherapists can agree and deliver a standardized package of treatment, which reflects current practice, as part of a randomized controlled trial.
[Show abstract][Hide abstract] ABSTRACT: The effective integration of research evidence into everyday clinical practice continues to be an important challenge.
The group aimed to answer locally relevant clinical question and produce recommendations for practice based on the best available evidence.
Through a new initiative, a multidisciplinary group with a specific interest in musculoskeletal disease has been established in order to help address this problem. The group consists of clinical and academic professionals including physiotherapists, occupational therapists, nurses, clinical researchers and information technology librarians representing the health economy.
Results from the group's activities are shared locally through presentations and clinical algorithms and nationally through conference presentations and the National Electronic Library for Health.
As well as clinical recommendations, other benefits of the group have been improved networking, enhanced continual professional development and identifying areas in need of further research.
Journal of Evaluation in Clinical Practice 11/2007; 13(5):703-8. · 1.51 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To introduce a new method of assessment; an observed structured clinical examination (OSCE) into a postgraduate course for rheumatology clinical nurse specialists.
The OSCE was introduced into a physical assessment module, which focused on the nurses' ability to perform an examination of patients' shoulders, knees and hands. A modified blueprinting exercise was used to ensure adequate sampling of the different components of the syllabus. This resulted in five active stations and one rest station. The active stations included history-taking, physical examination of the shoulder, knee and hand complexes and multidisciplinary management plans. To enhance authenticity real, rather than simulated, patients were used where practical.
All 11 students passed all stations, the lowest score related to history-taking and the highest score related to devising a management plan. All 11 students rated the OSCE a worthwhile experience reflecting the learning outcomes of the module and recommended that the OSCE should be used to assess the next cohort of students. Eight students found the OSCE too 'anxiety-provoking' and did not want this method of assessment to be used in other modules. All examiners felt this mode of assessment was more valid than the previous assessment format of a viva on a single patient.
This was the first time an OSCE was used in a postgraduate course to assess the physical examination skills of rheumatology nurse specialists. The course faculty, examiners and students found it was a reliable and valid means of assessment.
[Show abstract][Hide abstract] ABSTRACT: The concept of evidence-based practice (EBP) encourages health care professionals to provide the most effective health care, and to be accountable for the interventions they provide. Little work has been undertaken to examine how practically allied health professionals' encompass EBP and how they perceptive and understand the concept of EBP. The use of opinion leaders to disseminate new evidence into practice, and thereby encourage the behaviour of health care professionals has been proposed.
The aims of this study were to investigate physiotherapists' attitudes towards EBP and to examine change in their attitudes following an education package, which utilized local opinion leaders.
Thirty musculoskeletal physiotherapists from a Community Trust in North Staffordshire were cluster randomized by location of work to two groups. The intervention group received an evidence-based programme on aspects of EBP including literature searching and critical appraisal. The attention control group received a standard in-service training package on the management of common knee pathologies. The physiotherapists' attitudes towards EBP were measured at baseline (before randomization) and at 3 and 6 months follow-up.
Physiotherapists reported that they primarily relied on 'courses' and 'in-service training' for informing their clinical practice. Most agreed that clinical practice should be based on the best available evidence and that they would change their clinical practice if evidence suggested they should do so. However, many of the physiotherapists reported difficulty in reading journals and could not identify opinion leaders in key areas. In terms of clinical practice, literature, journals and research were ascribed low priority throughout. Differences in attitudes between the intervention and control groups were observed in relation to management support for EBP at 3 and 6 months follow-up.
In this study, physiotherapists appeared to be in favour of the idea of EBP, yet they remained reluctant to change their practice. Opinion leaders were not easily identifiable by physiotherapists, suggesting that this method alone may not be an effective method of changing attitudes in clinical practice. The process of changing attitudes in the clinical environment is a complex issue worthy of further research.
Journal of Evaluation in Clinical Practice 06/2004; 10(2):207-17. · 1.51 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Low back pain is a disabling condition that is responsible for a considerable amount of health service expenditure [HMSO, London, 1994, p. 1; The Back Pain Revolution. Churchill Livingstone, London, 1999]. Following national recommendations from the Clinical Standards Advisory Group [HMSO, London, 1994, p. 1] and the Royal College of General Practitioner Guidelines [Royal College of General Practice, London, 1996, 1999], local initiatives have attempted to integrate this advice into care pathways for low back pain. This paper will detail the background development, construction and audit of an integrated care pathway for the management of patients with acute low back pain in North Staffordshire.