Progressive exercise compared with best-practice advice, with or without corticosteroid injection, for rotator cuff disorders: the GRASP factorial RCT

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.

Carer administration of as-needed subcutaneous medication for breakthrough symptoms in people dying at home: the CARiAD feasibility RCT

BACKGROUND

Most people who are dying want to be cared for at home, but only half of them achieve this. The likelihood of a home death often depends on the availability of able and willing lay carers. When people who are dying are unable to take oral medication, injectable medication is used. When top-up medication is required, a health-care professional travels to the dying person's home, which may delay symptom relief. The administration of subcutaneous medication by lay carers, although not widespread UK practice, has proven to be key in achieving better symptom control for those dying at home in other countries.

OBJECTIVES

To determine if carer administration of as-needed subcutaneous medication for common breakthrough symptoms in people dying at home is feasible and acceptable in the UK, and if it would be feasible to test this intervention in a future definitive randomised controlled trial.

DESIGN

We conducted a two-arm, parallel-group, individually randomised, open pilot trial of the intervention versus usual care, with a 1 : 1 allocation ratio, using convergent mixed methods.

SETTING

Home-based care without 24/7 paid care provision, in three UK sites.

PARTICIPANTS

Participants were dyads of adult patients and carers: patients in the last weeks of their life who wished to die at home and lay carers who were willing to be trained to give subcutaneous medication. Strict risk assessment criteria needed to be met before approach, including known history of substance abuse or carer ability to be trained to competency.

INTERVENTION

Intervention-group carers received training by local nurses using a manualised training package.

MAIN OUTCOME MEASURES

Quantitative data were collected at baseline and 6-8 weeks post bereavement and via carer diaries. Interviews with carers and health-care professionals explored attitudes to, experiences of and preferences for giving subcutaneous medication and experience of trial processes. The main outcomes of interest were feasibility, acceptability, recruitment rates, attrition and selection of the most appropriate outcome measures.

RESULTS

In total, 40 out of 101 eligible dyads were recruited (39.6%), which met the feasibility criterion of recruiting > 30% of eligible dyads. The expected recruitment target (≈50 dyads) was not reached, as fewer than expected participants were identified. Although the overall retention rate was 55% (22/40), this was substantially unbalanced [30% (6/20) usual care and 80% (16/20) intervention]. The feasibility criterion of > 40% retention was, therefore, considered not met. A total of 12 carers (intervention, n = 10; usual care, n = 2) and 20 health-care professionals were interviewed. The intervention was considered acceptable, feasible and safe in the small study population. The context of the feasibility study was not ideal, as district nurses were seriously overstretched and unfamiliar with research methods. A disparity in readiness to consider the intervention was demonstrated between carers and health-care professionals. Findings showed that there were methodological and ethics issues pertaining to researching last days of life care.

CONCLUSION

The success of a future definitive trial is uncertain because of equivocal results in the progression criteria, particularly poor recruitment overall and a low retention rate in the usual-care group. Future work regarding the intervention should include understanding the context of UK areas where this has been adopted, ascertaining wider public views and exploring health-care professional views on burden and risk in the NHS context. There should be consideration of the need for national policy and of the most appropriate quantitative outcome measures to use. This will help to ascertain if there are unanswered questions to be studied in a trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN11211024.

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. 24, No. 25. See the NIHR Journals Library website for further project information.

Intra-axonal injection of biologically active materials

An improved method for injection of chemicals into the squid giant axon is described. A large number of metabolically active materials were found to be without any effect upon the action potential. Tetraethylammonium chloride produced a striking prolongation of the action potential. Cocaine and ethanol caused a transient reduction in the amplitude of the action potential. A filter paper eluate was found to contain materials which caused repetitive firing followed by a reduction in amplitude of the action potential and finally inexcitability.

EFFECTS PRODUCED ON INHIBITORY POSTSYNAPTIC POTENTIALS BY THE COUPLED INJECTIONS OF CATIONS AND ANIONS INTO MOTONEURONS

Ions have been injected into cat motoneurons impaled by a double microelectrode. Current has been passed down one barrel and up the other, so injecting cations out of the former and anions out of the latter. The injection of (K + + Cl - ) ions gave a depolarizing shift of the E IPSP almost as large as for a Cl - ion injection, and with a time course comparable with that for injections of Cl - or K + ions alone. The injection of (Na + + Cl - ) ions displaced the E IPSP by much the same amount and again the recovery time was almost as fast as after a Cl - ion injection, and much faster than after the injection of Na + ions alone. On the other hand injection of (2Na + + SO 2 4 - ions caused a slight displacement of the E IPSP in the hyperpolarizing direction. It was postulated that, when (K + ) i is depleted, there is an accelerated operation of an inward pump for (K + + Cl - ) ions with the consequence that the decline of high (Cl - ) i is slowed by a factor of three or more. The ion injection procedures did not provide evidence for or against the participation of K + ion movements in the generation of the IPSP , but this participation at a level comparable with that of Cl - ions had to be postulated in order to account for the normal hyperpolarizing character of the IPSP .

MYCOBACTERIUM FORTUITUM IN ABSCESSES OF MAN

Myco. fortuitum was isolated from subcutaneous abscesses of two patients who had been inoculated with B.C.G. and one patient who had iron injections. The organisms were resistant to a wide range of anti-tuberculous drugs. They were highly virulent for mice in which they produced symptoms of spinning disease. It is thought that the infections originated from contamination of syringes or skin.

THE EFFECT OF INTRA(CEREBRO)VENTRICULAR RESERPINE ON THE ACETYLCHOLINE CONTENT OF THE HEART, ILEUM AND HYPOTHALAMUS OF THE DOG

The effect of injection of reserpine into the cerebral ventricles on the acetylcholine contents of the sino-atrial node, ileum and hypothalamus of the dog was studied in ten dogs. Another group of five dogs served as a control. The effect of intravenous administration of reserpine, in the same dose as given intracerebroventricularly, was also studied on the acetylcholine content of these tissues in five dogs. General sedation, bradycardia, miosis, salivation, emesis and purgation were looked for. Tissues were removed 1 hr after administration of reserpine for estimation of acetylcholine content, which was increased in all the tissues studied. The increase in the peripheral tissues was greater than in the hypothalamus. The increase in the acetylcholine content was not quantitatively related to the other effects of reserpine. The increase in the acetylcholine content of the sino-atrial node and the ileum and also the peripheral effects observed on intracerebroventricular administration of reserpine can be attributed to its central action. With the same dose of reserpine given intravenously the acetylcholine content of the sino-atrial node was significantly increased, while that of the hypothalamus and ileum was not.

EFFECT OF ROUTE OF ADMINISTRATION ON THE CARCINOGENIC ACTION OF DIETHYLNITROSAMINE (N-NITROSODIETHYLAMINE)

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