Corticosteroid injection for de Quervain's tenosynovitis

Back ground De Quervain's tenosynovitis is a disorder characterised by pain on the radial (thumb) side of the wrist and functional disability of the hand. It can be treated by corticosteroid injection, splinting and surgery. Objectives To summarise evidence on the efficacy and safety of corticosteroid injections for de Quervain's tenosynovitis. Search strategy We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 2), MEDLINE (1966 to April 2009), EMBASE (1956 to April 2009), CINAHL (1982 to April 2009), AMED (1985 to April 2009), DARE, Dissertation Abstracts and PEDro (physiotherapy evidence database). Selection criteria Randomised and controlled clinical trials evaluating the efficacy and safety of corticosteroid injections for de Quervain's tenosynovitis. Data collection and analysis After screening abstracts of studies identified by the search we obtained full text articles of studies which fulfilled the selection criteria. We extracted data using a predefined electronic form. We assessed the methodological quality of included trials by using the checklist developed by Jadad and the Delphi list. We extracted data on the primary outcome measures: treatment success; severity of pain or tenderness at the radial styloid; functional impairment of the wrist or hand; and outcome of Finkelstein's test, and the secondary outcome measures: proportion of patients with side effects; type of side effects and patient satisfaction with injection treatment. Main results We found one controlled clinical trial of 18 participants (all pregnant or lactating women) that compared one steroid injection with methylprednisolone and bupivacaine to splinting with a thumb spica. All patients in the steroid injection group (9/9) achieved complete relief of pain whereas none of the patients in the thumb spica group (0/9) had complete relief of pain, one to six days after intervention (number needed to treat to benefit (NNTB) = 1, 95% confidence interval (CI) 0.8 to 1.2). No side effects or local complications of steroid injection were noted. Authors' conclusions The efficacy of corticosteroid injections for de Quervain's tenosynovitis has been studied in only one small controlled clinical trial, which found steroid injections to be superior to thumb spica splinting. However, the applicability of our findings to daily clinical practice is limited, as they are based on only one trial with a small number of included participants, the methodological quality was poor and only pregnant and lactating women participated in the study. No adverse effects were observed

Rationale, design and methods of the Study of Work and Pain (SWAP): a cluster randomised controlled trial testing the addition of a vocational advice service to best current primary care for patients with musculoskeletal pain (ISRCTN 52269669)

Background Musculoskeletal pain is a major contributor to short and long term work absence. Patients seek care from their general practitioner (GP) and yet GPs often feel ill-equipped to deal with work issues. Providing a vocational case management service in primary care, to support patients with musculoskeletal problems to remain at or return to work, is one potential solution but requires robust evaluation to test clinical and cost-effectiveness. Methods/Design This protocol describes a cluster randomised controlled trial, with linked qualitative interviews, to investigate the effect of introducing a vocational advice service into general practice, to provide a structured approach to managing work related issues in primary care patients with musculoskeletal pain who are absent from work or struggling to remain in work. General practices (n = 6) will be randomised to offer best current care or best current care plus a vocational advice service. Adults of working age who are absent from or struggling to remain in work due to a musculoskeletal pain problem will be invited to participate and 330 participants will be recruited. Data collection will be through patient completed questionnaires at baseline, 4 and 12 months. The primary outcome is self-reported work absence at 4 months. Incremental cost-utility analysis will be undertaken to calculate the cost per additional QALY gained and incremental net benefits. A linked interview study will explore the experiences of the vocational advice service from the perspectives of GPs, nurse practitioners (NPs), patients and vocational advisors. Discussion This paper presents the rationale, design, and methods of the Study of Work And Pain (SWAP) trial. The results of this trial will provide evidence to inform primary care practice and guide the development of services to provide support for musculoskeletal pain patients with work-related issues. Trial registration Current Controlled Trials ISRCTN52269669

Does age modify the relationship between morbidity severity and physical health in English and Dutch family practice populations?

PURPOSE: To investigate the co-influences of age and morbidity severity on physical health in adult family practice populations. METHODS: Morbidity data in a 12-month period for 7,833 older English consulters aged 50 years and over and 6,846 Dutch consulters aged 18 years and over was linked to their physical health status obtained from cross-sectional health surveys. Individual patients were categorised using 78 consulting morbidities classified by a chronicity measure (acute, acute-on-chronic and chronic) into an ordinal scale of morbidity severity ranging from single to multiple chronicity groups. Associations between morbidity severity, age and SF-12 Physical Component Summary (PCS) score were assessed using linear regression methods. RESULTS: Increased age and higher morbidity severity were significantly associated with poorer physical health. Of the explained total variance in adjusted PCS scores, an estimated 43% was attributed to increasing age, 40% to morbidity severity and 17% to deprivation for English consulters; the figures were 21, 42 and 31%, respectively for Dutch consulters. The largest differences in PCS scores between severity categories were observed in the younger age groups. CONCLUSIONS: Morbidity severity and age mainly act separately in adversely influencing physical health. In ageing populations who will experience higher multimorbidity, this study underlines the importance that health care and public health will need to address morbidity severity and ageing as related but distinct issue

Shoulder disorders in general practice: Incidence, patient characteristics, and management

Objectives-To study the incidence and management of intrinsic shoulder disorders in Dutch general practice, and to evaluate which patient characteristics are associated with specific diagnostic categories. Methods-In 11 general practices (35 150 registered patients) all consultations concerning shoulder complaints were registered during a period of one year. Patients with an intrinsic shoulder disorder who had not consulted their general practitioner for the complaint during the preceding year (incident cases) were asked to participate in an observational study. Participants completed a questionnaire regarding the nature and severity of their complaints. The general practitioners recorded data on diagnosis and therapy. Results-The cumulative incidence of shoulder complaints in general practice was estimated to be ll2/1000 patients/year (95% confidence limits 10.1 to 12.3). Rotator cuff tendinitis was the most frequently recorded disorder (29%). There were 349 incident cases enrolled in the observational study. Patient characteristics showed small variations between different diagnostic categories. Age, duration ofsymptoms, precipitating cause and restriction ofmovement seemed to be discriminating factors. Twenty two percent of all participants received injections during the first consultation; most (85%) were diagnosed as having bursitis. The majority of patients with tendinitis (53%) were referred for physiotherapy. Conclusion-With respect to diagnosis and treatment, the practitioners generally appeared to follow the guidelines issued by the Dutch College of General Practitioners. Although the patient characteristics of specific disorders showed some similarities with the clinical pictures described in the literature, further research is required to demonstrate whether the proposed syndromes indeed constitute separate disorders with a different underlying pathology, requiring different treatment strategies

Generalizability of a prediction rule for sick leave due to shoulder pain

Objectives Recently, a rule was developed to predict sick leave related to shoulder pain during a period of 6 months after patients have consulted a general practitioner for a new episode of shoulder pain. The objective was to evaluate the generalizability of this prediction rule by testing it in two other populations of workers who had gone for a consultation in primary care for a new episode of shoulder pain. Methods The prediction rule was derived in a prognostic cohort study (N=350). The outcome was sick leave related to shoulder pain during 6 months following the first consultation. The rule was tested on merged control groups from three trials on shoulder pain (N=128). In addition to this population, a recently conducted study on musculoskeletal disorders (N=224) was used to validate the prediction rule. The generalizability of the prediction rule was tested by studying calibration and discrimination in the validation cohorts. Results The prediction rule showed reasonable calibration in both validation cohorts. The discriminative ability, with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.70 in the derivation cohort was stable in the cohort of the musculoskeletal disorder study (AUC 0.71). In the control groups of the three randomized controlled trials of a Dutch shoulder study, the discriminative ability decreased to an AUC of 0.66. Conclusions The prediction rule for sick leave related to shoulder pain in a 6-month period following the first consultation in primary care showed adequate generalizability to another population of workers with shoulder pain participating in an observational cohort study. In the control groups of the three randomized controlled trials the prediction rule performed less well

Measuring practitioner/therapist effects in randomised trials of low back pain and neck pain interventions in primary care settings

In psychological health treatment studies it has been shown that differences between therapists account for some of the non-specific effect of treatment but this phenomenon has not so far systematically been investigated in musculoskeletal disorders. In this study we evaluated and compared the size and potential influence of the 'practitioner effect' (or 'therapist effect') in three randomised treatment trials of low back pain and neck pain patients in primary care. We calculated the proportion of variance in outcomes attributable to differences across practitioners, i.e. the practitioner-variance partition coefficient (p-vpc). As measures of outcome, we focused on self-reported disability as the primary outcome, but we also investigated assessed psychological outcomes. The p-vpc for the disability measures ranged from 2.6% to 7.1% across trials and time points (post treatment and follow up). Estimates differed between treatment subgroups within trials; being highest in treatment subgroups assigned to psychosocial-based interventions. A 'practitioner effect' does exist and is more pronounced in treatments involving greater psychosocial emphasis. This has implications for both practice and research in this clinical area. It highlights the importance of patient-practitioner interactions, and the need to address practitioner effects in designing and analysing outcome studies in low back pain and neck pain in primary car

Diagnostic accuracy of diagnostic imaging for lumbar disc herniation in adults with low back pain or sciatica is unknown; A systematic review

Main text: We aim to summarize the available evidence on the diagnostic accuracy of imaging (index test) compared to surgery (reference test) for identifying lumbar disc herniation (LDH) in adult patients. For this systematic review we searched MEDLINE, EMBASE and CINAHL (June 2017) for studies that assessed the diagnostic accuracy of imaging for LDH in adult patients with low back pain and surgery as the reference standard. Two review authors independently selected studies, extracted data and assessed risk of bias. We calculated summary estimates of sensitivity and specificity using bivariate analysis, generated linked ROC plots in case of direct comparison of diagnostic imaging tests and assessed the quality of evidence using the GRADE-approach. We found 14 studies, all but one done before 1995, including 940 patients. Nine studies investigated Computed Tomography (CT), eight myelography and six Magnetic Resonance Imaging (MRI). The prior probability of LDH varied from 48.6 to 98.7%. The summary estimates for MRI and myelography were comparable with CT (sensitivity: 81.3% (95%CI 72.3-87.7%) and specificity: 77.1% (95%CI 61.9-87.5%)). The quality of evidence was moderate to very low. Conclusions: The diagnostic accuracy of CT, myelography and MRI of today is unknown, as we found no studies evaluating today's more advanced imaging techniques. Concerning the older techniques we found moderate diagnostic accuracy for all CT, myelography and MRI, indicating a large proportion of false positives and negatives

Clinical and cost effectiveness of a corticosteroid injection versus exercise therapy for shoulder pain in general practice: Protocol for a randomised controlled trial (SIX Study)

Introduction Shoulder pain is common and the prognosis is often unfavourable. Dutch guidelines on the treatment of shoulder pain in primary care recommend a corticosteroid injection or a referral to exercise therapy, if initial pain management fails and pain persists. However, evidence of the effectiveness of a corticosteroid injection compared with exercise therapy, especially in the long term, is limited. This trial will assess the clinical effectiveness and cost effectiveness of a corticosteroid injection compared with physiotherapist-led exercise therapy over 12 months follow-up in patients with shoulder pain in primary care. Methods and analysis The SIX Study is a multicentre, pragmatic randomised clinical trial in primary care. A total of 213 patients with shoulder pain, aged ≥18 years presenting in general practice will be included. Patients will be randomised (1:1) into two groups: a corticosteroid injection or 12 sessions of physiotherapist-led exercise therapy. The effect of the allocated treatment will be assessed through questionnaires at 6 weeks and after 3, 6, 9 and 12 months. The primary outcome is patient's reported shoulder pain-intensity and function, measured with the Shoulder Pain and Disability Index, over 12 months follow-up. Secondary outcomes include cost effectiveness, pain-intensity, function, health-related quality of life, sleep quality, patient's global perceived effect, work absence, healthcare utilisation and adverse events. Between group differences will be evaluated using a repeated measurements analysis with linear effects models. A cost-utility analysis will be performed to assess the cost effectiveness using quality-adjusted life years from a medical and societal perspective. Ethics and dissemination This study was approved by the Medical Ethics Committee of Erasmus MC University Medical Center Rotterdam (MEC 2020-0300). All participants will give written informed consent prior to data collection. The results from this study will be disseminated in international journals and implemented in the primary care guidelines on shoulder pain. Trial registration number Dutch Trial Registry (NL8854)

Modifiable prognostic factors of high costs related to healthcare utilization among older people seeking primary care due to back pain: an identification and replication study

BACKGROUND: Back pain is an extensive burden to our healthcare system, yet few studies have explored modifiable prognostic factors associated with high costs related to healthcare utilization, especially among older back pain patients. The aims of this study were to identify modifiable prognostic factors for high costs related to healthcare utilization among older people seeking primary care with a new episode of back pain; and to replicate the identified associations in a similar cohort, in a different country. METHODS: Data from two cohort studies within the BACE consortium were used, including 452 and 675 people aged ≥55 years seeking primary care with a new episode of back pain. High costs were defined as costs in the top 25th percentile. Healthcare utilization was self-reported, aggregated for one-year of follow-up and included: primary care consultations, medications, examinations, hospitalization, rehabilitation stay and operations. Costs were estimated based on unit costs collected from national pricelists. Nine potential modifiable prognostic factors were selected based on previous literature. Univariable and multivariable binary logistic regression models were used to identify and replicate associations (crude and adjusted for selected covariates) between each modifiable prognostic factor and high costs related to healthcare utilization. RESULTS: Four modifiable prognostic factors associated with high costs related to healthcare utilization were identified and replicated: a higher degree of pain severity, disability, depression, and a lower degree of physical health-related quality of life. Kinesiophobia and recovery expectations showed no prognostic value. There were inconsistent results across the two cohorts with regards to comorbidity, radiating pain below the knee and mental health-related quality of life. CONCLUSION: The factors identified in this study may be future targets for intervention with the potential to reduce high costs related to healthcare utilization among older back pain patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT04261309, 07 February 2020. Retrospectively registered