Increasing capacity for the treatment of common musculoskeletal problems: A non-inferiority RCT and economic analysis of corticosteroid injection for shoulder pain comparing a physiotherapist and orthopaedic surgeon

Background Role substitution is a strategy employed to assist health services manage the growing demand for musculoskeletal care. Corticosteroid injection is a common treatment in this population but the efficacy of its prescription and delivery by physiotherapists has not been established against orthopaedic standards. This paper investigates whether corticosteroid injection given by a physiotherapist for shoulder pain is as clinically and cost effective as that from an orthopaedic surgeon. Methods A double blind non-inferiority randomized controlled trial was conducted in an Australian public hospital orthopaedic outpatient service, from January 2013 to June 2014. Adults with a General Practitioner referral to Orthopaedics for shoulder pain received subacromial corticosteroid and local anaesthetic injection prescribed and delivered independently by a physiotherapist or a consultant orthopaedic surgeon. The main outcome measure was total Shoulder Pain and Disability Index (SPADI) score at baseline, six and 12 weeks, applying a non-inferiority margin of 15 points. Secondary outcomes tested for superiority included pain, shoulder movement, perceived improvement, adverse events, satisfaction, quality of life and costs. Results 278 participants were independently assessed by the physiotherapist and the orthopaedic surgeon, with 64 randomised (physiotherapist 33, orthopaedic surgeon 31). There were no significant differences in baseline characteristics between groups. Non-inferiority of injection by the physiotherapist was declared from total SPADI scores at 6 and 12 weeks (upper limit of the 95% one-sided confidence interval 13.34 and 7.17 at 6 and 12 weeks, respectively). There were no statistically significant differences between groups on any outcome measures at 6 or 12 weeks. From the perspective of the health funder, the physiotherapist was less expensive. Conclusions Corticosteroid injection for shoulder pain, provided by a suitably qualified physiotherapist is at least as clinically effective, and less expensive, compared with similar care delivered by an orthopaedic surgeon. Policy makers and service providers should consider implementing this model of care

Treatment of myofascial trigger points in common shoulder disorders by physical therapy: A randomized controlled trial [ISRCTN75722066]

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Patient and physician perspective on sperm banking to overcome post-treatment lnfertility in young cancer patients in Pakistan

Background: Cancer survivor rates have increased over the past few decades leading to a growing interest in research related to quality of life (QoL). We attempted to explore the unique barriers that might prevent adult male cancer patients from accessing sperm cryopreservation in Pakistan. Methods: Semi-structured interviews of male cancer patients aged 18–45 years were audio-recorded in Urdu and translated to English and were transcribed ad verbatim. The topics included information regarding risk of infertility following chemotherapy, future reproductive choices, and barriers to sperm cryopreservation. Questionnaire to physicians containing four content domains of knowledge, attitude, practice, and barriers to sperm banking was also delivered. Data were entered and analyzed on SPSS. Results: Of the 25 patients interviewed, there were 10 cases of leukemia, 3 cases of lymphoma, 2 cases each of colorectal carcinoma and multiple myeloma, 1 case each of neuroblastoma and osteosarcoma, and solitary cases involving the lung, breast, thymus, brain, jaw, and testis. Four patients knew about the risk of infertility. All patients were aware of the option of sperm cryopreservation. Two patients had their sperm preserved before the initiation of chemotherapy. Perceived treatment-related expenses appeared to be the major barrier to sperm cryopreservation in nine patients. This was followed by lack of information, which was cited by eight patients, and religious reasons (n = 2 patients). Other barriers were female gender of the doctor and patient\u27s preferences. Four patients stated no barriers. Nine physicians responded to the questionnaire. Seventy-eight percent of physicians agreed that cancer treatment increases the risk of infertility. 33.3% strongly agreed and 55.6% agreed that infertility can have an adverse impact on QoL. Conclusions: There is a significant lack of awareness among male cancer patients regarding infertility following cancer treatment. It is imperative that physicians inform them of this and discuss treatment options, along with addressing potential barrier