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Archer L, Relton SD, Akbari A, Best K, Bucknall M, Conroy S, Hattle M, Hollinghurst J, Humphrey S, Lyons RA, Richards S, Walters K, West R, van der Windt D, Riley RD, Clegg A. Development and external validation of the eFalls tool: a multivariable prediction model for the risk of ED attendance or hospitalisation with a fall or fracture in older adults. Age Ageing 2024; 53:afae057. [PMID: 38520142 PMCID: PMC10960070 DOI: 10.1093/ageing/afae057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Falls are common in older adults and can devastate personal independence through injury such as fracture and fear of future falls. Methods to identify people for falls prevention interventions are currently limited, with high risks of bias in published prediction models. We have developed and externally validated the eFalls prediction model using routinely collected primary care electronic health records (EHR) to predict risk of emergency department attendance/hospitalisation with fall or fracture within 1 year. METHODS Data comprised two independent, retrospective cohorts of adults aged ≥65 years: the population of Wales, from the Secure Anonymised Information Linkage Databank (model development); the population of Bradford and Airedale, England, from Connected Bradford (external validation). Predictors included electronic frailty index components, supplemented with variables informed by literature reviews and clinical expertise. Fall/fracture risk was modelled using multivariable logistic regression with a Least Absolute Shrinkage and Selection Operator penalty. Predictive performance was assessed through calibration, discrimination and clinical utility. Apparent, internal-external cross-validation and external validation performance were assessed across general practices and in clinically relevant subgroups. RESULTS The model's discrimination performance (c-statistic) was 0.72 (95% confidence interval, CI: 0.68 to 0.76) on internal-external cross-validation and 0.82 (95% CI: 0.80 to 0.83) on external validation. Calibration was variable across practices, with some over-prediction in the validation population (calibration-in-the-large, -0.87; 95% CI: -0.96 to -0.78). Clinical utility on external validation was improved after recalibration. CONCLUSION The eFalls prediction model shows good performance and could support proactive stratification for falls prevention services if appropriately embedded into primary care EHR systems.
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Affiliation(s)
- Lucinda Archer
- Institute for Applied Health Research, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Samuel D Relton
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ashley Akbari
- Population Data Science, Swansea University Medical School, Swansea University, Swansea, UK
| | - Kate Best
- Academic Unit for Ageing and Stroke Research, University of Leeds, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - Simon Conroy
- Institute of Cardiovascular Science, University College London, London, UK
| | - Miriam Hattle
- Institute for Applied Health Research, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Joe Hollinghurst
- Population Data Science, Swansea University Medical School, Swansea University, Swansea, UK
| | - Sara Humphrey
- Bradford District and Craven Health and Care Partnership, Bradford, UK
| | - Ronan A Lyons
- Population Data Science, Swansea University Medical School, Swansea University, Swansea, UK
| | - Suzanne Richards
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Kate Walters
- Primary Care and Population Health, University College London, London, UK
| | - Robert West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Richard D Riley
- Institute for Applied Health Research, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Andrew Clegg
- Academic Unit for Ageing and Stroke Research, University of Leeds, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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Leaviss J, Carroll C, Essat M, van der Windt D, Grainge MJ, Card T, Riley R, Abhishek A. Prognostic factors for liver, blood and kidney adverse events from glucocorticoid sparing immune-suppressing drugs in immune-mediated inflammatory diseases: a prognostic systematic review. RMD Open 2024; 10:e003588. [PMID: 38199851 PMCID: PMC10806492 DOI: 10.1136/rmdopen-2023-003588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/23/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Immune-suppressing drugs can cause liver, kidney or blood toxicity. Prognostic factors for these adverse-events are poorly understood. PURPOSE To ascertain prognostic factors associated with liver, blood or kidney adverse-events in people receiving immune-suppressing drugs. DATA SOURCES MEDLINE, Web of Science, EMBASE and the Cochrane library (01 January 1995 to 05 January 2023), and supplementary sources. DATA EXTRACTION AND SYNTHESIS Data were extracted by one reviewer using a modified CHARMS-PF checklist and validated by another. Two independent reviewers assessed risk of bias using Quality in Prognostic factor Studies tool and assessed the quality of evidence using a Grading of Recommendations Assessment, Development and Evaluation-informed framework. RESULTS Fifty-six studies from 58 papers were included. High-quality evidence of the following associations was identified: elevated liver enzymes (6 studies) and folate non-supplementation (3 studies) are prognostic factors for hepatotoxicity in those treated with methotrexate; that mercaptopurine (vs azathioprine) (3 studies) was a prognostic factor for hepatotoxicity in those treated with thiopurines; that mercaptopurine (vs azathioprine) (3 studies) and poor-metaboliser status (4 studies) were prognostic factors for cytopenia in those treated with thiopurines; and that baseline elevated liver enzymes (3 studies) are a prognostic factor for hepatotoxicity in those treated with anti-tumour necrosis factors. Moderate and low quality evidence for several other demographic, lifestyle, comorbidities, baseline bloods/serologic or treatment-related prognostic factors were also identified. LIMITATIONS Studies published before 1995, those with less than 200 participants and not published in English were excluded. Heterogeneity between studies included different cut-offs for prognostic factors, use of different outcome definitions and different adjustment factors. CONCLUSIONS Prognostic factors for target-organ damage were identified which may be further investigated for their potential role in targeted (risk-stratified) monitoring. PROSPERO REGISTRATION NUMBER CRD42020208049.
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Affiliation(s)
- Joanna Leaviss
- SCHARR, The University of Sheffield, Sheffield, Yorkshire, UK
| | | | - Munira Essat
- SCHARR, The University of Sheffield, Sheffield, Yorkshire, UK
| | | | - Matthew J Grainge
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tim Card
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Richard Riley
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, Birmingham, UK
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Runhaar J, Holden MA, Hattle M, Quicke J, Healey EL, van der Windt D, Dziedzic KS, Middelkoop MV, Bierma-Zeinstra S, Foster NE. Mechanisms of action of therapeutic exercise for knee and hip OA remain a black box phenomenon: an individual patient data mediation study with the OA Trial Bank. RMD Open 2023; 9:e003220. [PMID: 37640513 PMCID: PMC10462947 DOI: 10.1136/rmdopen-2023-003220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/24/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVES To evaluate mediating factors for the effect of therapeutic exercise on pain and physical function in people with knee/hip osteoarthritis (OA). METHODS For Subgrouping and TargetEd Exercise pRogrammes for knee and hip OsteoArthritis (STEER OA), individual participant data (IPD) were sought from all published randomised controlled trials (RCTs) comparing therapeutic exercise to non-exercise controls in people with knee/hip OA. Using the Counterfactual framework, the effect of the exercise intervention and the percentage mediated through each potential mediator (muscle strength, proprioception and range of motion (ROM)) for knee OA and muscle strength for hip OA were determined. RESULTS Data from 12 of 31 RCTs of STEER OA (1407 participants) were available. Within the IPD data sets, there were generally statistically significant effects from therapeutic exercise for pain and physical function in comparison to non-exercise controls. Of all potential mediators, only the change in knee extension strength was statistically and significantly associated with the change in pain in knee OA (β -0.03 (95% CI -0.05 to -0.01), 2.3% mediated) and with physical function in knee OA (β -0.02 (95% CI -0.04 to -0.00), 2.0% mediated) and hip OA (β -0.03 (95% CI -0.07 to -0.00), no mediation). CONCLUSIONS This first IPD mediation analysis of this scale revealed that in people with knee OA, knee extension strength only mediated ±2% of the effect of therapeutic exercise on pain and physical function. ROM and proprioception did not mediate changes in outcomes, nor did knee extension strength in people with hip OA. As 98% of the effectiveness of therapeutic exercise compared with non-exercise controls remains unexplained, more needs to be done to understand the underlying mechanisms of actions.
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Affiliation(s)
- Jos Runhaar
- General Practice, Erasmus MC, Rotterdam, The Netherlands
| | - Melanie A Holden
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | - Miriam Hattle
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | - Jonathan Quicke
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
- Chartered Society of Physiotherapy, London, UK
| | - Emma Louise Healey
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | | | - Krysia S Dziedzic
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | | | - Sita Bierma-Zeinstra
- General Practice, Erasmus MC, Rotterdam, The Netherlands
- Orthopedics & Sports Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Nadine E Foster
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
- Surgical Treatment and Rehabilitation Service (STARS) Education and Research Alliance, The University of Queensland and Metro North Health, Brisbane, Queensland, Australia
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Burton C, Rathod-Mistry T, Blackburn S, Blagojevic-Bucknall M, Chesterton L, Davenport G, Dziedzic K, Higginbottom A, Jowett S, Myers H, Oppong R, van der Windt D, Hay E, Roddy E. The effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome: 24-month follow-up of a randomized trial. Rheumatology (Oxford) 2023; 62:546-554. [PMID: 35394019 PMCID: PMC9891401 DOI: 10.1093/rheumatology/keac219] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/04/2022] [Accepted: 04/04/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES This follow-up study of the INSTinCTS (INjection vs SplinTing in Carpal Tunnel Syndrome) trial compared the effects of corticosteroid injection (CSI) and night splinting (NS) for the initial management of mild-to-moderate CTS on symptoms, resource use and carpal tunnel surgery, over 24 months. METHODS Adults with mild-to-moderate CTS were randomized 1:1 to a local corticosteroid injection or a night splint worn for 6 weeks. Outcomes at 12 and 24 months included the Boston Carpal Tunnel Questionnaire (BCTQ), hand/wrist pain intensity numeric rating scale (NRS), the number of patients referred for and undergoing CTS surgery, and healthcare utilization. A cost-utility analysis was conducted. RESULTS One hundred and sixteen participants received a CSI and 118 a NS. The response rate at 24 months was 73% in the CSI arm and 71% in the NS arm. By 24 months, a greater proportion of the CSI group had been referred for (28% vs 20%) and undergone (22% vs 16%) CTS surgery compared with the NS group. There were no statistically significant between-group differences in BCTQ score or pain NRS at 12 or 24 months. CSI was more costly [mean difference £68.59 (95% CI: -120.84, 291.24)] with fewer quality-adjusted life-years than NS over 24 months [mean difference -0.022 (95% CI: -0.093, 0.045)]. CONCLUSION Over 24 months, surgical intervention rates were low in both groups, but less frequent in the NS group. While there were no differences in the clinical effectiveness of CSI and NS, initial treatment with CSI may not be cost-effective in the long-term compared with NS.
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Affiliation(s)
- Claire Burton
- School of Medicine and Primary Care Centre Versus Arthritis, Keele University, Staffordshire, UK
| | - Trishna Rathod-Mistry
- School of Medicine and Primary Care Centre Versus Arthritis, Keele University, Staffordshire, UK
| | - Steven Blackburn
- School of Medicine and Primary Care Centre Versus Arthritis, Keele University, Staffordshire, UK
| | | | - Linda Chesterton
- School of Medicine and Primary Care Centre Versus Arthritis, Keele University, Staffordshire, UK
| | - Graham Davenport
- School of Medicine and Primary Care Centre Versus Arthritis, Keele University, Staffordshire, UK
| | - Krysia Dziedzic
- School of Medicine and Primary Care Centre Versus Arthritis, Keele University, Staffordshire, UK
| | - Adele Higginbottom
- School of Medicine and Primary Care Centre Versus Arthritis, Keele University, Staffordshire, UK.,Patient and Public Involvement and Engagement Coordinator
| | - Sue Jowett
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - Helen Myers
- School of Medicine and Primary Care Centre Versus Arthritis, Keele University, Staffordshire, UK
| | - Raymond Oppong
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - Danielle van der Windt
- School of Medicine and Primary Care Centre Versus Arthritis, Keele University, Staffordshire, UK
| | - Elaine Hay
- School of Medicine and Primary Care Centre Versus Arthritis, Keele University, Staffordshire, UK
| | - Edward Roddy
- School of Medicine and Primary Care Centre Versus Arthritis, Keele University, Staffordshire, UK.,Haywood Academic Rheumatology Centre, Midlands Partnership NHS Foundation Trust, Stoke-on-Trent, UK
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Abstract
OBJECTIVE Summarise longitudinal observational studies to determine whether diabetes (types 1 and 2) is a risk factor for frozen shoulder. DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE, Embase, AMED, PsycINFO, Web of Science Core Collection, CINAHL, Epistemonikos, Trip, PEDro, OpenGrey and The Grey Literature Report were searched on January 2019 and updated in June 2021. Reference screening and emailing professional contacts were also used. ELIGIBILITY CRITERIA Longitudinal observational studies that estimated the association between diabetes and developing frozen shoulder. DATA EXTRACTION AND SYNTHESIS Data extraction was completed by one reviewer and independently checked by another using a predefined extraction sheet. Risk of bias was judged using the Quality In Prognosis Studies tool. For studies providing sufficient data, random-effects meta-analysis was used to derive summary estimates of the association between diabetes and the onset of frozen shoulder. RESULTS A meta-analysis of six case-control studies including 5388 people estimated the odds of developing frozen shoulder for people with diabetes to be 3.69 (95% CI 2.99 to 4.56) times the odds for people without diabetes. Two cohort studies were identified, both suggesting diabetes was associated with frozen shoulder, with HRs of 1.32 (95% CI 1.22 to 1.42) and 1.67 (95% CI 1.46 to 1.91). Risk of bias was judged as high in seven studies and moderate in one study. CONCLUSION People with diabetes are more likely to develop frozen shoulder. Risk of unmeasured confounding was the main limitation of this systematic review. High-quality studies are needed to confirm the strength of, and understand reasons for, the association. PROSPERO REGISTRATION NUMBER CRD42019122963.
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Affiliation(s)
- Brett Paul Dyer
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Newcastle-under-Lyme, UK
| | - Trishna Rathod-Mistry
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Newcastle-under-Lyme, UK
| | - Claire Burton
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Newcastle-under-Lyme, UK
| | - Danielle van der Windt
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Newcastle-under-Lyme, UK
| | - Milica Bucknall
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Newcastle-under-Lyme, UK
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6
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Hill JC, Garvin S, Bromley K, Saunders B, Kigozi J, Cooper V, Lewis M, Protheroe J, Wathall S, Chudyk A, Dunn KM, Birkinshaw H, Jowett S, Hay EM, van der Windt D, Mallen C, Foster NE. Risk-based stratified primary care for common musculoskeletal pain presentations (STarT MSK): a cluster-randomised, controlled trial. Lancet Rheumatol 2022; 4:e591-e602. [PMID: 36386549 PMCID: PMC9649927 DOI: 10.1016/s2665-9913(22)00159-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
BACKGROUND Risk-based stratified care shows clinical effectiveness and cost-effectiveness versus usual primary care for non-specific low back pain but is untested for other common musculoskeletal disorders. We aimed to test the clinical effectiveness and cost-effectiveness of point-of-care risk stratification (using Keele's STarT MSK Tool and risk-matched treatments) versus usual care for the five most common musculoskeletal presentations (back, neck, knee, shoulder, and multi-site pain). METHODS In this cluster-randomised, controlled trial in UK primary care with embedded qualitative and health economic studies we recruited patients from 24 general practices in the West Midlands region of England. Eligible patients were those aged 18 years or older whose general practitioner (GP) confirmed a consultation for a musculoskeletal presentation. General practices that consented to participate via a representative of the cluster were randomly assigned (1:1) to intervention or usual care, using stratified block randomisation. Researchers involved in data collection, outcome data entry, and statistical analysis were masked at both the cluster and individual participant level. Participating patients were told the study was examining GP treatment of common aches and pains and were not aware they were in a randomised trial. GPs in practices allocated to the intervention group were supported to deliver risk-based stratified care using a bespoke computer-based template, including the risk-stratification tool, and risk-matched treatment options for patients at low, medium, or high risk of poor disability or pain outcomes. There were 15 risk-matched treatment options. In the usual care group, patients with musculoskeletal pain consulting their GP received treatment as usual, typically including advice and education, medication, referral for investigations or tests, or referral to other services. The primary outcome was time-averaged pain intensity over 6 months. All analyses were done by intention to treat. The trial is registered with ISRCTN, ISRCTN15366334. RESULTS Between May 1, 2018, and April 30, 2019, 104 GPs from 24 practices (12 per study group) identified 2494 patients with musculoskeletal pain. 1211 (49%) participants consented to questionnaires (534 in the intervention group and 677 in the usual care group), with 1070 (88%) completing the follow-up questionnaire at 6 months. We found no significant difference in time-averaged pain intensity (mean(SD) mean 4·4 [SD 2·3] in the intervention group vs 4·6 [2·5] in the control group; adjusted mean difference -0·16, 95% CI -0·65 to 0·34) or in standardised function score (mean -0·06 [SD 0·94] in the intervention group vs 0·05 [1·04]; adjusted mean difference -0·07, 95% CI -0·22 to 0·08). No serious adverse events or adverse events were reported. Risk stratification received positive patient and clinician feedback. INTERPRETATION Risk stratification for patients in primary care with common musculoskeletal presentations did not lead to significant improvements in pain or function, although some aspects of GP decision making were affected, and GP and patients had positive experiences. The costs of risk-based stratified care were similar to usual care, and such a strategy only offers marginal changes in cost-effectiveness outcomes. The clinical implications from this trial are largely inconclusive. FUNDING National Institute for Health Research.
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Affiliation(s)
- Jonathan C Hill
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
- Correspondence to: Prof Jonathan C Hill, Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire ST5 5BG, UK
| | | | - Kieran Bromley
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
- Keele Clinical Trials Unit, Keele University, Staffordshire, UK
| | - Benjamin Saunders
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
| | - Jesse Kigozi
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Vince Cooper
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
| | - Martyn Lewis
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
- Keele Clinical Trials Unit, Keele University, Staffordshire, UK
| | - Joanne Protheroe
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
| | - Simon Wathall
- Keele Clinical Trials Unit, Keele University, Staffordshire, UK
| | - Adrian Chudyk
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
| | - Kate M Dunn
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
| | - Hollie Birkinshaw
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
| | - Sue Jowett
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Elaine M Hay
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
| | - Danielle van der Windt
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
| | - Christian Mallen
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
| | - Nadine E Foster
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
- STARS Education and Research Alliance, Surgical Treatment and Rehabilitation Service, University of Queensland and Metro North Health, QLD, Australia
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Killingmo RM, Storheim K, van der Windt D, Zolic-Karlsson Z, Vigdal ØN, Kretz L, Småstuen MC, Grotle M. Healthcare utilization and related costs among older people seeking primary care due to back pain: findings from the BACE-N cohort study. BMJ Open 2022; 12:e057778. [PMID: 35725262 PMCID: PMC9214384 DOI: 10.1136/bmjopen-2021-057778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To describe healthcare utilization and estimate associated costs during 1 year of follow-up among older people seeking primary care due to a new episode back pain and to describe healthcare utilization across patients with different risk profiles stratified using the StarT Back Screening Tool (SBST). DESIGN Prospective cohort study. PARTICIPANTS AND SETTING A total of 452 people aged ≥55 years seeking Norwegian primary care with a new episode of back pain were included. OUTCOME MEASURES The primary outcome of this study was total cost of healthcare utilization aggregated for 1 year of follow-up. Secondary outcomes included components of healthcare utilization aggregated for 1 year of follow-up. Healthcare utilization was self-reported and included: primary care consultations, medications, examinations, hospitalisation, rehabilitation stay, and operations. Costs were estimated based on unit costs collected from national pricelists. Healthcare utilization across patients with different SBST risk profiles was compared using Kruskal-Wallis test, post hoc Mann-Whitney U tests and Bonferroni adjustment. RESULTS In total, 438 patients were included in the analysis. Mean (BCa 95% CI) total cost per patient over 1 year was €825 (682-976). Median (BCa 95% CI) total cost was €364 (307-440). The largest cost category was primary care consultations, accounting for 56% of total costs. Imaging rate was 34%. The most commonly used medication was paracetamol (27%-35% of patients). Medium- and high-risk patients had a significantly higher degree of healthcare utilization compared with low-risk patients (p<0.030). CONCLUSION This study estimated a 1 year mean and median cost of healthcare utilization of €825 and €364, respectively. Patients within the top 25th percentile accounted for 77% of all costs. Patients classified as medium risk and high risk had a significantly higher degree of healthcare utilization compared with patients classified as low risk. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT04261309, results.
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Affiliation(s)
| | - Kjersti Storheim
- Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
- Research and Communication Unit for Musculoskeletal Health (FORMI), Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
| | | | | | | | - Lise Kretz
- Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
| | | | - Margreth Grotle
- Department of Physiotherapy, Oslo Metropolitan University, Oslo, Norway
- Research and Communication Unit for Musculoskeletal Health (FORMI), Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
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Nakafero G, Grainge MJ, Card T, Mallen CD, Riley R, van der Windt D, Fox CP, Taal MW, Aithal GP, Williams HC, Abhishek A. Incidence and pattern of mycophenolate discontinuation associated with abnormal monitoring blood-test results: cohort study using data from the Clinical Practice Research Datalink Aurum. Rheumatol Adv Pract 2022; 6:rkac046. [PMID: 35702565 PMCID: PMC9187914 DOI: 10.1093/rap/rkac046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/18/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objective
To examine the incidence and pattern of mycophenolate discontinuation associated with abnormal monitoring blood-tests.
Methods
Data from people prescribed mycophenolate for common inflammatory conditions in the Clinical Practice Research Datalink was used. Participants were followed from first mycophenolate prescription. Primary outcome was drug discontinuation with an associated abnormal blood-test result within 60 days. Secondary outcomes were drug discontinuation for any reason, and discontinuations associated with severely abnormal blood-test results within 60 days. Multivariable cox-regression was used to examine factors associated with primary outcome.
Results
The cohort included 992 participants (68.9% female, mean age 51.95 years, 47.1% with SLE) contributing 1,885 person-years of follow-up. The incidence of mycophenolate discontinuation associated with any (severely) abnormal blood-test results was 153.46 (21.07) per 1000 person-years in the first, and 32.39 (7.91) per 1000 person-years in later years of prescription, respectively. 11.5% (1.7%) patients prescribed mycophenolate discontinued treatment with any (severely) abnormal blood-test results in the first year of prescription. After this period mean 2.6% (0.7%) patients discontinued treatment with any (severely) abnormal blood-test results per year. Increased serum creatinine and cytopenia were more commonly associated with mycophenolate discontinuation than elevated liver enzymes. CKD-stage ≥3 was significantly associated with mycophenolate discontinuation with any blood-test abnormalities (aHR (95%CI) 2.22 (1.47–3.37)).
Conclusion
Mycophenolate is uncommonly discontinued for blood-test abnormalities, and, even less often discontinued for severe blood-test abnormalities after the first year of prescription. Consideration may be given for less frequent monitoring after one-year of treatment, especially in those without CKD-stage ≥3.
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Affiliation(s)
- Georgina Nakafero
- University of Nottingham Academic Rheumatology, School of Medicine, , Nottingham, UK
| | - Matthew J Grainge
- University of Nottingham Lifespan and Population Health, School of Medicine, , Nottingham, UK
| | - Tim Card
- University of Nottingham Lifespan and Population Health, School of Medicine, , Nottingham, UK
- University of Nottingham Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, , Nottingham, UK
| | - Christian D Mallen
- Keele University Primary Care Centre Versus Arthritis, School of Medicine, , Keele, UK
| | - Richard Riley
- Keele University Primary Care Centre Versus Arthritis, School of Medicine, , Keele, UK
| | | | - Christopher P Fox
- Nottingham University Hospitals NHS Trust Department of Haematology, , Nottingham, UK
| | - Maarten W Taal
- University on Nottingham Centre for Kidney Research and Innovation, Translational Medical Sciences, School of Medicine, , Nottingham, UK
| | - Guruprasad P Aithal
- University of Nottingham Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, , Nottingham, UK
- NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust, and the University of Nottingham , Nottingham, UK
| | - Hywel C Williams
- University of Nottingham Centre of Evidence-Based Dermatology, School of Medicine, , Nottingham, UK
| | - Abhishek Abhishek
- University of Nottingham Academic Rheumatology, School of Medicine, , Nottingham, UK
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9
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Farooq S, Hattle M, Dazzan P, Kingstone T, Ajnakina O, Shiers D, Nettis MA, Lawrence A, Riley R, van der Windt D. Study protocol for the development and internal validation of Schizophrenia Prediction of Resistance to Treatment (SPIRIT): a clinical tool for predicting risk of treatment resistance to antipsychotics in first-episode schizophrenia. BMJ Open 2022; 12:e056420. [PMID: 35396294 PMCID: PMC8996048 DOI: 10.1136/bmjopen-2021-056420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 03/16/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Treatment-resistant schizophrenia (TRS) is associated with significant impairment of functioning and high treatment costs. Identification of patients at high risk of TRS at the time of their initial diagnosis may significantly improve clinical outcomes and minimise social and functional disability. We aim to develop a prognostic model for predicting the risk of developing TRS in patients with first-episode schizophrenia and to examine its potential utility and acceptability as a clinical decision tool. METHODS AND ANALYSIS We will use two well-characterised longitudinal UK-based first-episode psychosis cohorts: Aetiology and Ethnicity in Schizophrenia and Other Psychoses and Genetics and Psychosis for which data have been collected on sociodemographic and clinical characteristics. We will identify candidate predictors for the model based on current literature and stakeholder consultation. Model development will use all data, with the number of candidate predictors restricted according to available sample size and event rate. A model for predicting risk of TRS will be developed based on penalised regression, with missing data handled using multiple imputation. Internal validation will be undertaken via bootstrapping, obtaining optimism-adjusted estimates of the model's performance. The clinical utility of the model in terms of clinically relevant risk thresholds will be evaluated using net benefit and decision curves (comparative to competing strategies). Consultation with patients and clinical stakeholders will determine potential thresholds of risk for treatment decision-making. The acceptability of embedding the model as a clinical tool will be explored using qualitative focus groups with up to 20 clinicians in total from early intervention services. Clinicians will be recruited from services in Stafford and London with the focus groups being held via an online platform. ETHICS AND DISSEMINATION The development of the prognostic model will be based on anonymised data from existing cohorts, for which ethical approval is in place. Ethical approval has been obtained from Keele University for the qualitative focus groups within early intervention in psychosis services (ref: MH-210174). Suitable processes are in place to obtain informed consent for National Health Service staff taking part in interviews or focus groups. A study information sheet with cover letter and consent form have been prepared and approved by the local Research Ethics Committee. Findings will be shared through peer-reviewed publications, conference presentations and social media. A lay summary will be published on collaborator websites.
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Affiliation(s)
- Saeed Farooq
- Midlands Partnership NHS Foundation Trust, Stafford, Staffordshire, UK
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Miriam Hattle
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Paola Dazzan
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Tom Kingstone
- Midlands Partnership NHS Foundation Trust, Stafford, Staffordshire, UK
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Olesya Ajnakina
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - David Shiers
- School of Medicine, Keele University, Keele, Staffordshire, UK
- Psychosis Research Unit, Greater Manchester Mental Health NHS Trust, Manchester, UK
- Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Maria Antonietta Nettis
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, University of London, London, UK
| | - Andrew Lawrence
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, University of London, London, UK
| | - Richard Riley
- School of Medicine, Keele University, Keele, Staffordshire, UK
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Clegg A, Bandeen-Roche K, Farrin A, Forster A, Gill TM, Gladman J, Kerse N, Lindley R, McManus RJ, Melis R, Mujica-Mota R, Raina P, Rockwood K, Teh R, van der Windt D, Witham M. New horizons in evidence-based care for older people: individual participant data meta-analysis. Age Ageing 2022; 51:afac090. [PMID: 35460409 PMCID: PMC9034697 DOI: 10.1093/ageing/afac090] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
Evidence-based decisions on clinical and cost-effectiveness of interventions are ideally informed by meta-analyses of intervention trial data. However, when undertaken, such meta-analyses in ageing research have typically been conducted using standard methods whereby summary (aggregate) data are extracted from published trial reports. Although meta-analysis of aggregate data can provide useful insights into the average effect of interventions within a selected trial population, it has limitations regarding robust conclusions on which subgroups of people stand to gain the greatest benefit from an intervention or are at risk of experiencing harm. Future evidence synthesis using individual participant data from ageing research trials for meta-analysis could transform understanding of the effectiveness of interventions for older people, supporting evidence-based and sustainable commissioning. A major advantage of individual participant data meta-analysis (IPDMA) is that it enables examination of characteristics that predict treatment effects, such as frailty, disability, cognitive impairment, ethnicity, gender and other wider determinants of health. Key challenges of IPDMA relate to the complexity and resources needed for obtaining, managing and preparing datasets, requiring a meticulous approach involving experienced researchers, frequently with expertise in designing and analysing clinical trials. In anticipation of future IPDMA work in ageing research, we are establishing an international Ageing Research Trialists collective, to bring together trialists with a common focus on transforming care for older people as a shared ambition across nations.
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Affiliation(s)
- Andrew Clegg
- Academic Unit for Ageing & Stroke Research, University of Leeds, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Karen Bandeen-Roche
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amanda Farrin
- Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - Anne Forster
- Academic Unit for Ageing & Stroke Research, University of Leeds, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Thomas M Gill
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | | | - Ngaire Kerse
- Department of General Practice and Primary Health Care, University of Auckland School of Population Health, Auckland, New Zealand
| | - Richard Lindley
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Ruben Mujica-Mota
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Parminder Raina
- Department of Health Evidence and Impact & McMaster Institute for Research on Aging, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Kenneth Rockwood
- Division of Geriatric Medicine, Dalhousie University, Halifax, Canada
| | - Ruth Teh
- Department of General Practice and Primary Health Care, University of Auckland School of Population Health, Auckland, New Zealand
| | | | - Miles Witham
- AGE Research Group, Newcastle University, Newcastle, UK
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11
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Major DH, Røe Y, Småstuen MC, van der Windt D, Sandbakk TB, Jæger M, Grotle M. Fear of movement and emotional distress as prognostic factors for disability in patients with shoulder pain: a prospective cohort study. BMC Musculoskelet Disord 2022; 23:183. [PMID: 35219313 PMCID: PMC8882288 DOI: 10.1186/s12891-022-05139-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 02/21/2022] [Indexed: 02/08/2023] Open
Abstract
Abstract
Background
Shoulder pain is a prevalent and often long-lasting musculoskeletal disorder. The overall prognosis of shoulder pain is highly variable with 40–50% of patients reporting persistent pain 6–12 months after consulting a clinician. The evidence for psychological prognostic factors for patients with shoulder pain is inconsistent. Therefore, the objective of this study was to investigate the association between fear of movement and emotional distress at presentation and self-reported disability over one year of follow-up.
Methods
This is a prospective cohort study of consecutive patients referred to secondary outpatient care due to shoulder pain. Consenting patients underwent a physical examination and completed a comprehensive questionnaire at baseline, three months-, and one-year follow-up. Associations between baseline fear of movement (0–10) or emotional distress (1–4), respectively, and patient reported disability measured using Quick Disability of the Arm and Shoulder (QuickDASH, 0–100) over one year were analyzed with linear mixed-effects models (LMM) for repeated measures (baseline, 3 months and 1 year), adjusting for established prognostic factors.
Results
A total of 138 patients were recruited between March 2015 and January 2018, with response rates of 84.7% (n = 117) and 79.7% (n = 100) at three months and one year, respectively. Adjusted associations revealed that for every point increase in baseline fear of movement, the QuickDASH score increased (worsened) by 1.10 points (95% CI 0.2–2.0) over the follow-up year. For every point increase in baseline emotional distress, the QuickDASH score increased by 19.9 points (95% CI 13.9–25.9) from baseline over the follow-up year.
Conclusion
Higher fear of movement and emotional distress scores at baseline were significantly associated with higher disability over one year in patients with shoulder pain referred to secondary care. Our study indicates that these psychological factors affect prognosis and should be considered by clinicians and researchers working with patients with shoulder pain.
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12
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Wynne-Jones G, Myers H, Hall A, Littlewood C, Hennings S, Saunders B, Bucknall M, Jowett S, Riley R, Wathall S, Heneghan C, Cook J, Pincus T, Mallen C, Roddy E, Foster N, Beard D, Lewis J, Rees JL, Higginbottom A, van der Windt D. Predicting pain and function outcomes in people consulting with shoulder pain: the PANDA-S clinical cohort and qualitative study protocol. BMJ Open 2021; 11:e052758. [PMID: 34535486 PMCID: PMC8451291 DOI: 10.1136/bmjopen-2021-052758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION People presenting with shoulder pain considered to be of musculoskeletal origin is common in primary care but diagnosing the cause of the pain is contentious, leading to uncertainty in management. To inform optimal primary care for patients with shoulder pain, the study aims to (1) to investigate the short-term and long-term outcomes (overall prognosis) of shoulder pain, (2) estimate costs of care, (3) develop a prognostic model for predicting individuals' level and risk of pain and disability at 6 months and (4) investigate experiences and opinions of patients and healthcare professionals regarding diagnosis, prognosis and management of shoulder pain. METHODS AND ANALYSIS The Prognostic And Diagnostic Assessment of the Shoulder (PANDA-S) study is a longitudinal clinical cohort with linked qualitative study. At least 400 people presenting to general practice and physiotherapy services in the UK will be recruited. Participants will complete questionnaires at baseline, 3, 6, 12, 24 and 36 months. Short-term data will be collected weekly between baseline and 12 weeks via Short Message Serevice (SMS) text or software application. Participants will be offered clinical (physiotherapist) and ultrasound (sonographer) assessments at baseline. Qualitative interviews with ≈15 dyads of patients and their healthcare professional (general practitioner or physiotherapist).Short-term and long-term trajectories of Shoulder Pain and Disability Index (using SPADI) will be described, using latent class growth analysis. Health economic analysis will estimate direct costs of care and indirect costs related to work absence and productivity losses. Multivariable regression analysis will be used to develop a prognostic model predicting future levels of pain and disability at 6 months using penalisation methods to adjust for overfitting. The added predictive value of prespecified physical examination tests and ultrasound findings will be examined. For the qualitative interviews an inductive, exploratory framework will be adopted using thematic analysis to investigate decision making, perspectives of patients and clinicians on the importance of diagnostic and prognostic information when negotiating treatment and referral options. ETHICS AND DISSEMINATION The PANDA-S study has ethical approval from Yorkshire and The Humber-Sheffield Research Ethics Committee, UK (18/YH/0346, IRAS Number: 242750). Results will be disseminated through peer-reviewed publications, social and mainstream media, professional conferences, and the patient and public involvement and engagement group supporting this study, and through newsletters, leaflets and posters in participating sites. TRIAL REGISTRATION NUMBER ISRCTN46948079.
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Affiliation(s)
| | - Helen Myers
- Clinical Trials Unit, Keele University, Keele, UK
| | - Alison Hall
- School of Medicine, Keele University, Keele, UK
| | - Chris Littlewood
- School of Medicine, Keele University, Keele, UK
- Department of Health Professions, Manchester Metropolitan University, Manchester, UK
| | - S Hennings
- Clinical Trials Unit, Keele University, Keele, UK
| | | | | | - Sue Jowett
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | | | | | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Johanna Cook
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Tamar Pincus
- Psychology, Royal Hollaway University of London, London, UK
| | | | | | - Nadine Foster
- School of Medicine, Keele University, Keele, UK
- STARS Education and Research Alliance, The University of Queensland, Saint Lucia, Queensland, Australia
| | - David Beard
- Nuffield Dept of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jeremy Lewis
- School of Health and Social Work, University of Hertfordshire, Hatfield, UK
- Central London Community Healthcare NHS Trust, London, UK
| | - J L Rees
- Nuffield Dept of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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13
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Willmore E, McRobert C, Foy C, Stratton I, van der Windt D. What is the optimum rehabilitation for patients who have undergone release procedures for frozen shoulder? A UK survey. Musculoskelet Sci Pract 2021; 52:102319. [PMID: 33588155 DOI: 10.1016/j.msksp.2021.102319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 11/25/2020] [Accepted: 01/04/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Despite usually being considered necessary, the rehabilitation regime that optimises outcomes for patients following release procedures for frozen shoulder has not been established and no accepted best practice guidelines currently exist. The purpose of this study was to gain insight into what physiotherapists considered best practice and factors they considered likely to affect patient outcome. METHODS A cross-sectional, self-administered online questionnaire was developed and distributed to UK based Physiotherapists, undergraduate students and support workers via email, social media and professional networks. RESULTS 260 eligible and fully completed surveys were received. Clear preference for early (within 72 h), frequent (2-3 times per week or weekly) and prolonged (greater than 6 weeks) treatment delivered in a 1:1 setting was expressed. 99% were highly likely/likely to advocate education and advice, range of movement exercises (99.6%), stretching (73.5%) and strengthening (61.9%). More passive modalities (manual therapy, massage, electrotherapy, acupuncture) were highly unlikely/unlikely to be used and lack of manual therapy and insufficient contact with a physiotherapist were the reasons deemed least likely to affect outcome. Most clinicians (89.2%) were likely to prescribe exercises that patients reported as painful but persistent pain and poor adherence by patients to exercises were the top reasons given for poor outcome along with psychological and psychosocial patient characteristics. CONCLUSION Physiotherapists consistently advocate early, frequent, prolonged, 1:1 treatment following release procedures for frozen shoulder. Most patients are discharged whilst still experiencing symptoms, particularly pain. Further work is needed to establish high value pathways for this patient group.
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Affiliation(s)
| | - Cliona McRobert
- School of Health Sciences, Institute of Population Health, University of Liverpool, UK
| | - Chris Foy
- Gloucestershire Hospitals NHS Foundation Trust, UK
| | | | - Danielle van der Windt
- School for Primary, Community and Social Care, Centre for Prognosis Research, Primary Centre, Versus Arthritis, Keele University, Staffordshire, ST5 3BG, UK
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14
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Hill J, Garvin S, Chen Y, Cooper V, Wathall S, Bartlam B, Saunders B, Lewis M, Protheroe J, Chudyk A, Birkinshaw H, Dunn KM, Jowett S, Oppong R, Hay E, van der Windt D, Mallen C, Foster NE. Computer-Based Stratified Primary Care for Musculoskeletal Consultations Compared With Usual Care: Study Protocol for the STarT MSK Cluster Randomized Controlled Trial. JMIR Res Protoc 2020; 9:e17939. [PMID: 32442141 PMCID: PMC7381066 DOI: 10.2196/17939] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Musculoskeletal (MSK) pain is a major cause of pain and disability. We previously developed a prognostic tool (Start Back Tool) with demonstrated effectiveness in guiding primary care low back pain management by supporting decision making using matched treatments. A logical next step is to determine whether prognostic stratified care has benefits for a broader range of common MSK pain presentations. OBJECTIVE This study seeks to determine, in patients with 1 of the 5 most common MSK presentations (back, neck, knee, shoulder, and multisite pain), whether stratified care involving the use of the Keele Start MSK Tool to allocate individuals into low-, medium-, and high-risk subgroups, and matching these subgroups to recommended matched clinical management options, is clinical and cost-effective compared with usual nonstratified primary care. METHODS This is a pragmatic, two-arm parallel (stratified vs nonstratified care), cluster randomized controlled trial, with a health economic analysis and mixed methods process evaluation. The setting is UK primary care, involving 24 average-sized general practices randomized (stratified by practice size) in a 1:1 ratio (12 per arm) with blinding of trial statistician and outcome data collectors. Randomization units are general practices, and units of observation are adult MSK consulters without indicators of serious pathologies, urgent medical needs, or vulnerabilities. Potential participant records are tagged and individuals invited using a general practitioner (GP) point-of-consultation electronic medical record (EMR) template. The intervention is supported by an EMR template (computer-based) housing the Keele Start MSK Tool (to stratify into prognostic subgroups) and the recommended matched treatment options. The primary outcome using intention-to-treat analysis is pain intensity, measured monthly over 6 months. Secondary outcomes include physical function and quality of life, and an anonymized EMR audit to capture clinician decision making. The economic evaluation is focused on the estimation of incremental quality-adjusted life years and MSK pain-related health care costs. The process evaluation is exploring a range of potential factors influencing the intervention and understanding how it is perceived by patients and clinicians, with quantitative analyses focusing on a priori hypothesized intervention targets and qualitative approaches using focus groups and interviews. The target sample size is 1200 patients from 24 general practices, with >5000 MSK consultations available for anonymized medical record data comparisons. RESULTS Trial recruitment commenced on May 18, 2018, and ended on July 15, 2019, after a 14-month recruitment period in 24 GP practices. Follow-up and interview data collection was completed in February 2020. CONCLUSIONS This trial is the first attempt, as far as we know, at testing a prognostic stratified care approach for primary care patients with MSK pain. The results of this trial should be available by the summer of 2020. TRIAL REGISTRATION ISRCTN Registry ISRCTN15366334; http://www.isrctn.com/ISRCTN15366334. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/17939.
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Affiliation(s)
- Jonathan Hill
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Stefannie Garvin
- Keele Clinical Trials Unit, Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Ying Chen
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Vincent Cooper
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Simon Wathall
- Keele Clinical Trials Unit, Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | | | - Benjamin Saunders
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Martyn Lewis
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Joanne Protheroe
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Adrian Chudyk
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Hollie Birkinshaw
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Kate M Dunn
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Sue Jowett
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Raymond Oppong
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Elaine Hay
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Danielle van der Windt
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Christian Mallen
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
| | - Nadine E Foster
- Institute for Primary, Community and Social Care, Keele University, Stoke-on-Trent, United Kingdom
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15
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Marshall M, Jonsson H, Helgadottir GP, Nicholls E, Myers H, Jansen V, van der Windt D. Longitudinal validity of using digital hand photographs for assessing hand osteoarthritis progression over 7 years in community-dwelling older adults with hand pain. BMC Musculoskelet Disord 2019; 20:484. [PMID: 31656178 PMCID: PMC6815403 DOI: 10.1186/s12891-019-2829-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/12/2019] [Indexed: 11/28/2022] Open
Abstract
Background To determine the longitudinal construct validity of assessing hand OA progression on digital photographs over 7 years compared with progression determined from radiographs, clinical features and change in symptoms. Methods Participants were community-dwelling older adults (≥50 years) in North Staffordshire, UK. Standardized digital hand photographs were taken at baseline and 7 years, and hand joints graded for OA severity using an established photographic atlas. Radiographic hand OA was assessed using the Kellgren and Lawrence grading system. Hand examination determined the presence of nodes, bony enlargement and deformity. Symptoms were reported in self-complete questionnaires. Radiographic and clinical progression and change in symptoms were compared to photographic progression. Differences were examined using analysis of covariance and Chi-Square tests. Results Of 253 individuals (61% women, mean age 63 years) the proportion with photographic progression at the joint and joint group-level was higher in individuals with radiographic or clinical progression compared to those without, although differences were not statistically significant. At the person-level, those with moderate photographic progression over 7 years had significantly higher summed radiographic and clinical scores (adjusted for baseline scores) compared to those with no or mild photographic progression. Similar findings were observed for change in symptoms, although differences were small and not statistically significant. Conclusion Assessing hand OA on photographs shows modest longitudinal construct validity over 7 years compared with change in radiographic and clinical hand OA at the person-level. Using photographs to assess overall long-term change in a person with hand OA may be a reasonable alternative when hand examinations and radiographs are not feasible.
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Affiliation(s)
- Michelle Marshall
- Arthritis Research UK Primary Care Centre, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK.
| | - Helgi Jonsson
- Department of Rheumatology, Landspitalinn University Hospital, University of Iceland, IS-108 Fossvogur, Reykjavik, Iceland
| | | | - Elaine Nicholls
- Arthritis Research UK Primary Care Centre, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Helen Myers
- Arthritis Research UK Primary Care Centre, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Victoria Jansen
- Pulvertaft Hand Centre, Royal Derby Hospital, Derbyshire, DE22 3NE, UK
| | - Danielle van der Windt
- Arthritis Research UK Primary Care Centre, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
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16
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Konstantinou K, Dunn KM, van der Windt D, Ogollah R, Jasani V, Foster NE. Subgrouping patients with sciatica in primary care for matched care pathways: development of a subgrouping algorithm. BMC Musculoskelet Disord 2019; 20:313. [PMID: 31272439 PMCID: PMC6611047 DOI: 10.1186/s12891-019-2686-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 06/20/2019] [Indexed: 12/21/2022] Open
Abstract
Background Sciatica is a painful condition managed by a stepped care approach for most patients. Currently, there are no decision-making tools to guide matching care pathways for patients with sciatica without evidence of serious pathology, early in their presentation. This study sought to develop an algorithm to subgroup primary care patients with sciatica, for initial decision-making for matched care pathways, including fast-track referral to investigations and specialist spinal opinion. Methods This was an analysis of existing data from a UK NHS cohort study of patients consulting in primary care with sciatica (n = 429). Factors potentially associated with referral to specialist services, were identified from the literature and clinical opinion. Percentage of patients fast-tracked to specialists, sensitivity, specificity, positive and negative predictive values for identifying this subgroup, were calculated. Results The algorithm allocates patients to 1 of 3 groups, combining information about four clinical characteristics, and risk of poor prognosis (low, medium or high risk) in terms of pain-related persistent disability. Patients at low risk of poor prognosis, irrespective of clinical characteristics, are allocated to group 1. Patients at medium risk of poor prognosis who have all four clinical characteristics, and patients at high risk of poor prognosis with any three of the clinical characteristics, are allocated to group 3. The remainder are allocated to group 2. Sensitivity, specificity and positive predictive value of the algorithm for patient allocation to fast-track group 3, were 51, 73 and 22% respectively. Conclusion We developed an algorithm to support clinical decisions regarding early referral for primary care patients with sciatica. Limitations of this study include the low positive predictive value and use of data from one cohort only. On-going research is investigating whether the use of this algorithm and the linked care pathways, leads to faster resolution of sciatica symptoms. Electronic supplementary material The online version of this article (10.1186/s12891-019-2686-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kika Konstantinou
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK. .,Haywood Hospital, Midlands Partnership NHS Foundation Trust, Stoke-on-Trent, Staffordshire, ST6 7AG, UK.
| | - Kate M Dunn
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Danielle van der Windt
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Reuben Ogollah
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Keele Clinical Trials Unit, Keele University, Staffordshire, ST5 5BG, UK.,Present address: Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Vinay Jasani
- Department of Spine Surgery, University Hospital North Midlands, Royal Stoke University Hospital, Newcastle Rd, Stoke-on-Trent, ST4 6QG, UK
| | - Nadine E Foster
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Keele Clinical Trials Unit, Keele University, Staffordshire, ST5 5BG, UK
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Hay E, Dziedzic K, Foster N, Peat G, van der Windt D, Bartlam B, Blagojevic-Bucknall M, Edwards J, Healey E, Holden M, Hughes R, Jinks C, Jordan K, Jowett S, Lewis M, Mallen C, Morden A, Nicholls E, Ong BN, Porcheret M, Wulff J, Kigozi J, Oppong R, Paskins Z, Croft P. Optimal primary care management of clinical osteoarthritis and joint pain in older people: a mixed-methods programme of systematic reviews, observational and qualitative studies, and randomised controlled trials. Programme Grants Appl Res 2018. [DOI: 10.3310/pgfar06040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BackgroundOsteoarthritis (OA) is the most common long-term condition managed in UK general practice. However, care is suboptimal despite evidence that primary care and community-based interventions can reduce OA pain and disability.ObjectivesThe overall aim was to improve primary care management of OA and the health of patients with OA. Four parallel linked workstreams aimed to (1) develop a health economic decision model for estimating the potential for cost-effective delivery of primary care OA interventions to improve population health, (2) develop and evaluate new health-care models for delivery of core treatments and support for self-management among primary care consulters with OA, and to investigate prioritisation and implementation of OA care among the public, patients, doctors, health-care professionals and NHS trusts, (3) determine the effectiveness of strategies to optimise specific components of core OA treatment using the example of exercise and (4) investigate the effect of interventions to tackle barriers to core OA treatment, using the example of comorbid anxiety and depression in persons with OA.Data sourcesThe North Staffordshire Osteoarthritis Project database, held by Keele University, was the source of data for secondary analyses in workstream 1.MethodsWorkstream 1 used meta-analysis and synthesis of published evidence about effectiveness of primary care treatments, combined with secondary analysis of existing longitudinal population-based cohort data, to identify predictors of poor long-term outcome (prognostic factors) and design a health economic decision model to estimate cost-effectiveness of different hypothetical strategies for implementing optimal primary care for patients with OA. Workstream 2 used mixed methods to (1) develop and test a ‘model OA consultation’ for primary care health-care professionals (qualitative interviews, consensus, training and evaluation) and (2) evaluate the combined effect of a computerised ‘pop-up’ guideline for general practitioners (GPs) in the consultation and implementing the model OA consultation on practice and patient outcomes (parallel group intervention study). Workstream 3 developed and investigated in a randomised controlled trial (RCT) how to optimise the effect of exercise in persons with knee OA by tailoring it to the individual and improving adherence. Workstream 4 developed and investigated in a cluster RCT the extent to which screening patients for comorbid anxiety and depression can improve OA outcomes. Public and patient involvement included proposal development, project steering and analysis. An OA forum involved public, patient, health professional, social care and researcher representatives to debate the results and formulate proposals for wider implementation and dissemination.ResultsThis programme provides evidence (1) that economic modelling can be used in OA to extrapolate findings of cost-effectiveness beyond the short-term outcomes of clinical trials, (2) about ways of implementing support for self-management and models of optimal primary care informed by National Institute for Health and Care Excellence recommendations, including the beneficial effects of training in a model OA consultation on GP behaviour and of pop-up screens in GP consultations on the quality of prescribing, (3) against adding enhanced interventions to current effective physiotherapy-led exercise for knee OA and (4) against screening for anxiety and depression in patients with musculoskeletal pain as an addition to current best practice for OA.ConclusionsImplementation of evidence-based care for patients with OA is feasible in general practice and has an immediate impact on improving the quality of care delivered to patients. However, improved levels of quality of care, changes to current best practice physiotherapy and successful introduction of psychological screening, as achieved by this programme, did not substantially reduce patients’ pain and disability. This poses important challenges for clinical practice and OA research.LimitationsThe key limitation in this work is the lack of improvement in patient-reported pain and disability despite clear evidence of enhanced delivery of evidence-based care.Future work recommendations(1) New thinking and research is needed into the achievable and desirable long-term goals of care for people with OA, (2) continuing investigation into the resources needed to properly implement clinical guidelines for management of OA as a long-term condition, such as regular monitoring to maintain exercise and physical activity and (3) new research to identify subgroups of patients with OA as a basis for stratified primary care including (i) those with good prognosis who can self-manage with minimal investigation or specialist treatment, (ii) those who will respond to, and benefit from, specific interventions in primary care, such as physiotherapy-led exercise, and (iii) develop research into effective identification and treatment of clinically important anxiety and depression in patients with OA and into the effects of pain management on psychological outcomes in patients with OA.Trial registrationCurrent Controlled Trials ISRCTN06984617, ISRCTN93634563 and ISRCTN40721988.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research Programme and will be published in full inProgramme Grants for Applied Research Programme; Vol. 6, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Elaine Hay
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Krysia Dziedzic
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Nadine Foster
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - George Peat
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Danielle van der Windt
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Bernadette Bartlam
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Milisa Blagojevic-Bucknall
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - John Edwards
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Emma Healey
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Melanie Holden
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Rhian Hughes
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Clare Jinks
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Kelvin Jordan
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Sue Jowett
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Martyn Lewis
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Christian Mallen
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Andrew Morden
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Elaine Nicholls
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Bie Nio Ong
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Mark Porcheret
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Jerome Wulff
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Jesse Kigozi
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Raymond Oppong
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Zoe Paskins
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - Peter Croft
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK
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Babatunde OO, Legha A, Littlewood C, Chesterton LS, Thomas MJ, Menz HB, van der Windt D, Roddy E. Comparative effectiveness of treatment options for plantar heel pain: a systematic review with network meta-analysis. Br J Sports Med 2018; 53:182-194. [PMID: 29954828 DOI: 10.1136/bjsports-2017-098998] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate the comparative effectiveness of current treatment options for plantar heel pain (PHP). DESIGN Systematic review and network meta-analysis (NMA). DATA SOURCES Medline, EMBASE, CINAHL, AMED, PEDro, Cochrane Database, Web of Science and WHO Clinical Trials Platform were searched from their inception until January 2018. STUDY SELECTION Randomised controlled trials (RCTs) of adults with PHP investigating common treatments (ie, corticosteroid injection, non-steroidal anti-inflammatory drugs, therapeutic exercise, orthoses and/or extracorporeal shockwave therapy (ESWT)) compared with each other or a no treatment, placebo/sham control. DATA EXTRACTION AND ANALYSIS Data were extracted and checked for accuracy and completeness by pairs of reviewers. Primary outcomes were pain and function. Comparative treatment effects were analysed by random effects NMA in the short term, medium term and long term. Relative ranking of treatments was assessed by surface under the cumulative ranking probabilities (0-100 scale). RESULTS Thirty-one RCTs (total n=2450 patients) were included. There was no evidence of inconsistency detected between direct and indirect treatment comparisons in the networks, but sparse data led to frequently wide CIs. Available evidence does not suggest that any of the commonly used treatments for the management of PHP are better than any other, although corticosteroid injections, alone or in combination with exercise, and ESWT were ranked most likely to be effective for the management of short-term, medium-term and long-term pain or function; placebo/sham/control appeared least likely to be effective; and exercise appeared to only be beneficial for long-term pain or function. CONCLUSIONS Current evidence is equivocal regarding which treatment is the most effective for the management of PHP. Given limited understanding of long-term effects, there is need for large, methodologically robust multicentre RCTs investigating and directly comparing commonly used treatments for the management of PHP. PROSPERO REGISTRATION NUMBER CRD42016046963.
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Affiliation(s)
- Opeyemi O Babatunde
- Research Institute for Primary Care & Health Sciences, Arthritis Research UK Primary Care Centre, Keele, Staffordshire, UK
| | - Amardeep Legha
- Research Institute for Primary Care & Health Sciences, Arthritis Research UK Primary Care Centre, Keele, Staffordshire, UK.,Centre for Prognosis Research, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - Chris Littlewood
- Research Institute for Primary Care & Health Sciences, Arthritis Research UK Primary Care Centre, Keele, Staffordshire, UK
| | - Linda S Chesterton
- Research Institute for Primary Care & Health Sciences, Arthritis Research UK Primary Care Centre, Keele, Staffordshire, UK
| | - Martin J Thomas
- Research Institute for Primary Care & Health Sciences, Arthritis Research UK Primary Care Centre, Keele, Staffordshire, UK.,Haywood Academic Rheumatology Centre, Staffordshire and Stoke-on-Trent Partnership NHS Trust, Haywood Hospital, Burslem, Staffordshire, UK
| | - Hylton B Menz
- Research Institute for Primary Care & Health Sciences, Arthritis Research UK Primary Care Centre, Keele, Staffordshire, UK.,School of Allied Health, College of Science, Health and Engineering, La Trobe University, Bundoora Victoria, Australia
| | - Danielle van der Windt
- Research Institute for Primary Care & Health Sciences, Arthritis Research UK Primary Care Centre, Keele, Staffordshire, UK.,Centre for Prognosis Research, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - Edward Roddy
- Research Institute for Primary Care & Health Sciences, Arthritis Research UK Primary Care Centre, Keele, Staffordshire, UK.,Haywood Academic Rheumatology Centre, Staffordshire and Stoke-on-Trent Partnership NHS Trust, Haywood Hospital, Burslem, Staffordshire, UK
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19
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Konstantinou K, Dunn KM, Ogollah R, Lewis M, van der Windt D, Hay EM. Prognosis of sciatica and back-related leg pain in primary care: the ATLAS cohort. Spine J 2018; 18:1030-1040. [PMID: 29174459 PMCID: PMC5984249 DOI: 10.1016/j.spinee.2017.10.071] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 10/18/2017] [Accepted: 10/26/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Evidence is lacking on the prognosis and prognostic factors of back-related leg pain and sciatica in patients seeing their primary care physicians. This evidence could guide timely appropriate treatment and referral decisions. PURPOSE The present study aims to describe the prognosis and prognostic factors in primary care patients with low back-related leg pain and sciatica. STUDY DESIGN This is a prospective cohort study. PATIENT SAMPLE The present study included adults visiting their family doctor with back-related leg pain in the United Kingdom. OUTCOME MEASURES Information about pain, function, psychological, and clinical variables, was collected. Good outcome was defined as 30% or more reduction in disability (Roland-Morris Disability Questionnaire). METHODS Participants completed the questionnaires, underwent clinical assessments, received a magnetic resonance imaging scan, and were followed-up 12 months later. Mixed-effects logistic regression evaluated the prognostic value of six a priori defined variable sets (leg pain duration, pain intensity, neuropathic pain, psychological factors, clinical examination, and imaging variables). A combined model, including variables from all models, examined independent effects. The National Institute for Health Research funded the study. There are no conflicts of interest. RESULTS A total of 609 patients were included. At 12 months, 55% of patients improved in both the total sample and the sciatica group. For the whole cohort, longer leg pain duration (odds ratio [OR] 0.41; confidence interval [CI] 0.19-0.90), higher identity score (OR 0.70; CI 0.53-0.93), and patient's belief that the problem will last a long time (OR 0.27; CI 0.13-0.57) were the strongest independent prognostic factors negatively associated with improvement. These last two factors were similarly negatively associated with improvement in the sciatica subgroup. CONCLUSIONS The present study provides new evidence on the prognosis and prognostic factors of back-related leg pain and sciatica in primary care. Just over half of patients improved at 12 months. Patient's belief of recovery timescale and number of other symptoms attributed to the pain are independent prognostic factors. These factors can be used to inform and direct decisions about timing and intensity of available therapeutic options.
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Affiliation(s)
- Kika Konstantinou
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire ST5 5BG, United Kingdom.
| | - Kate M Dunn
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire ST5 5BG, United Kingdom
| | - Reuben Ogollah
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire ST5 5BG, United Kingdom
| | - Martyn Lewis
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire ST5 5BG, United Kingdom
| | - Danielle van der Windt
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire ST5 5BG, United Kingdom
| | - Elaine M Hay
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire ST5 5BG, United Kingdom
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Burke DL, Ensor J, Snell KI, van der Windt D, Riley RD. Guidance for deriving and presenting percentage study weights in meta-analysis of test accuracy studies. Res Synth Methods 2018; 9:163-178. [DOI: 10.1002/jrsm.1283] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 07/21/2017] [Accepted: 10/23/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Danielle L. Burke
- Research Institute for Primary Care and Health Sciences; Keele University; Keele Staffordshire ST5 5BG UK
| | - Joie Ensor
- Research Institute for Primary Care and Health Sciences; Keele University; Keele Staffordshire ST5 5BG UK
| | - Kym I.E. Snell
- Research Institute for Primary Care and Health Sciences; Keele University; Keele Staffordshire ST5 5BG UK
| | - Danielle van der Windt
- Research Institute for Primary Care and Health Sciences; Keele University; Keele Staffordshire ST5 5BG UK
| | - Richard D. Riley
- Research Institute for Primary Care and Health Sciences; Keele University; Keele Staffordshire ST5 5BG UK
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21
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Foster NE, Konstantinou K, Lewis M, Ogollah R, Dunn KM, van der Windt D, Beardmore R, Artus M, Bartlam B, Hill JC, Jowett S, Kigozi J, Mallen C, Saunders B, Hay EM. The clinical and cost-effectiveness of stratified care for patients with sciatica: the SCOPiC randomised controlled trial protocol (ISRCTN75449581). BMC Musculoskelet Disord 2017; 18:172. [PMID: 28441971 PMCID: PMC5405475 DOI: 10.1186/s12891-017-1513-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 03/31/2017] [Indexed: 12/16/2022] Open
Abstract
Background Sciatica has a substantial impact on patients, and is associated with high healthcare and societal costs. Although there is variation in the clinical management of sciatica, the current model of care usually involves an initial period of ‘wait and see’ for most patients, with simple measures of advice and analgesia, followed by conservative and/or more invasive interventions if symptoms fail to resolve. A model of care is needed that does not over-treat those with a good prognosis yet identifies patients who do need more intensive treatment to help with symptoms, and return to everyday function including work. The aim of the SCOPiC trial (SCiatica Outcomes in Primary Care) is to establish whether stratified care based on subgrouping using a combination of prognostic and clinical information, with matched care pathways, is more effective than non-stratified care, for improving time to symptom resolution in patients consulting with sciatica in primary care. We will also assess the impact of stratified care on service delivery and evaluate its cost-effectiveness compared to non-stratified care. Methods/Design Multicentre, pragmatic, parallel arm randomised trial, with internal pilot, cost-effectiveness analysis and embedded qualitative study. We will recruit 470 adult patients with sciatica from general practices in England and Wales, over 24 months. Patients will be randomised to stratified care or non-stratified care, and treated in physiotherapy and spinal specialist services, in participating NHS services. The primary outcome is time to first resolution of sciatica symptoms, measured on a 6-point ordered categorical scale, collected using text messaging. Secondary outcomes include physical function, pain intensity, quality of life, work loss, healthcare use and satisfaction with treatment, and will be collected using postal questionnaires at 4 and 12-month follow-up. Semi-structured qualitative interviews with a subsample of participants and clinicians will explore the acceptability of stratified care. Discussion This paper presents the details of the rationale, design and processes of the SCOPiC trial. Results from this trial will contribute to the evidence base for management of patients with sciatica consulting in primary care. Trial registration ISRCTN75449581, date: 20.11.2014.
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Affiliation(s)
- Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Keele Clinical Trials Unit, Keele University, Staffordshire, ST5 5BG, UK
| | - Kika Konstantinou
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.
| | - Martyn Lewis
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Keele Clinical Trials Unit, Keele University, Staffordshire, ST5 5BG, UK
| | - Reuben Ogollah
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Keele Clinical Trials Unit, Keele University, Staffordshire, ST5 5BG, UK
| | - Kate M Dunn
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Danielle van der Windt
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Ruth Beardmore
- Keele Clinical Trials Unit, Keele University, Staffordshire, ST5 5BG, UK
| | - Majid Artus
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Bernadette Bartlam
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Jonathan C Hill
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Sue Jowett
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Health Economics Unit Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Jesse Kigozi
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.,Health Economics Unit Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Christian Mallen
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Benjamin Saunders
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
| | - Elaine M Hay
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
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Dunn KM, Campbell P, Afolabi EK, Lewis M, van der Windt D, Hill JC, Mallen CD, Protheroe J, Hay EM, Foster NE. 176. REFINEMENT AND VALIDATION OF THE KEELE START MSK TOOL FOR MUSCULOSKELETAL PAIN IN PRIMARY CARE. Rheumatology (Oxford) 2017. [DOI: 10.1093/rheumatology/kex062.177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Buchbinder R, Page MJ, Huang H, Verhagen AP, Beaton D, Kopkow C, Lenza M, Jain NB, Richards B, Richards P, Voshaar M, van der Windt D, Gagnier JJ. A Preliminary Core Domain Set for Clinical Trials of Shoulder Disorders: A Report from the OMERACT 2016 Shoulder Core Outcome Set Special Interest Group. J Rheumatol 2017; 44:1880-1883. [DOI: 10.3899/jrheum.161123] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2016] [Indexed: 01/14/2023]
Abstract
Objective.The Outcome Measures in Rheumatology (OMERACT) Shoulder Core Outcome Set Special Interest Group (SIG) was established to develop a core outcome set (COS) for clinical trials of shoulder disorders.Methods.In preparation for OMERACT 2016, we systematically examined all outcome domains and measurement instruments reported in 409 randomized trials of interventions for shoulder disorders published between 1954 and 2015. Informed by these data, we conducted an international Delphi consensus study including shoulder trial experts, clinicians, and patients to identify key domains that should be included in a shoulder disorder COS. Findings were discussed at a stakeholder premeeting of OMERACT. At OMERACT 2016, we sought consensus on a preliminary core domain set and input into next steps.Results.There were 13 and 15 participants at the premeeting and the OMERACT 2016 SIG meeting, respectively (9 attended both meetings). Consensus was reached on a preliminary core domain set consisting of an inner core of 4 domains: pain, physical function/activity, global perceived effect, and adverse events including death. A middle core consisted of 3 domains: emotional well-being, sleep, and participation (recreation and work). An outer core of research required to inform the final COS was also formulated.Conclusion.Our next steps are to (1) analyze whether participation (recreation and work) should be in the inner core, (2) conduct a third Delphi round to finalize definitions and wording of domains and reach final endorsement for the domains, and (3) determine which instruments fulfill the OMERACT criteria for measuring each domain.
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Bedson J, Dunn K, Dent S, van der Windt D. Design, validity and clinical utility of smartphone app to assess short-term pain trajectories. Trials 2015. [PMCID: PMC4658690 DOI: 10.1186/1745-6215-16-s2-o62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Marshall M, Jonsson H, Helgadottir GP, Nicholls E, van der Windt D, Myers H, Dziedzic K. Reliability of Assessing Hand Osteoarthritis on Digital Photographs and Associations With Radiographic and Clinical Findings. Arthritis Care Res (Hoboken) 2015; 66:828-36. [PMID: 26259552 PMCID: PMC4153954 DOI: 10.1002/acr.22225] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 10/22/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the reliability and construct validity of an atlas for grading hand osteoarthritis (OA) on photographs in a separate younger community-dwelling population than the development cohort. METHODS Participants were community-dwelling adults (ages ≥50 years) in North Staffordshire, UK with hand pain or hand problems in the last year who attended a research clinic. High-quality photographs were taken in a standardized position. A photographic atlas was used to score hand joints (second and third distal interphalangeal [DIP], second and third proximal interphalangeal [PIP], and first carpometacarpal [CMC] joints) and joint groups (DIP, PIP, and CMC joints) for OA on a 0-3 scale. Hand radiographs were graded for OA using the Kellgren/Lawrence (K/L) grading system. Clinical features (nodes, bony enlargement, and deformity) were determined by physical examination. Associations of photographic hand OA grades with radiographic OA and clinical features were determined to assess construct validity. RESULTS In total, 558 participants (mean age 64 years, 62% women) were included in the analyses. Reliability for scoring OA on the photographs was good (mean intrarater intraclass correlation coefficient [ICC] 0.77 and mean interrater ICC 0.71). At the joint level, photographic hand OA grade was positively associated with radiographic OA grade (Spearman's ρ = 0.19-0.57, P < 0.001) and the number of clinical features (Spearman's ρ = 0.36-0.59, P < 0.001). At the person level, individuals with higher global photographic OA scores had higher summed K/L scores and higher percentages meeting the American College of Rheumatology clinical hand OA criteria. CONCLUSION This photographic scoring system was reliable and a good indicator of hand OA in a separate younger community-dwelling population than the development cohort. This method of data collection offers researchers a feasible alternative to physical examination and radiography.
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Affiliation(s)
- Michelle Marshall
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Staffordshire, UK
| | - Helgi Jonsson
- Landspitalinn University Hospital and University of Iceland, Reykjavik, Iceland
| | | | - Elaine Nicholls
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Staffordshire, UK
| | - Danielle van der Windt
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Staffordshire, UK
| | - Helen Myers
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Staffordshire, UK
| | - Krysia Dziedzic
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Staffordshire, UK
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Mansell G, Shapley M, van der Windt D, Sanders T, Little P. Critical items for assessing risk of lung and colorectal cancer in primary care: a Delphi study. Br J Gen Pract 2014; 64:e509-15. [PMID: 25071064 PMCID: PMC4111344 DOI: 10.3399/bjgp14x681001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 04/15/2014] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Patients with lung or colorectal cancer often present late and have a poor prognosis. Identifying diagnostic indicators to optimally assess the risk of these cancers in primary care would support early identification and timely referral for patients at increased risk. AIM To obtain consensus regarding potential diagnostic indicators that are important for assessing the risk of lung or colorectal cancer in primary care consulters presenting with lung or abdominal symptoms. DESIGN AND SETTING A Delphi study was conducted with 28 participants from primary and secondary care and academic settings in the UK and Europe. METHOD Indicators were obtained from systematic reviews, recent primary studies and consultation with experts prior to the Delphi study being conducted. Over three rounds, participants rated each diagnostic indicator in terms of its importance, ranked them in order of importance, and rated each item as crucial or not crucial to assess during a GP consultation. RESULTS The final round resulted in 25 items remaining for each type of cancer, including established cancer symptoms such as rectal bleeding for colorectal cancer and haemoptysis for lung cancer, but also less frequently used indicators such as patients' concerns about cancer. CONCLUSION This study highlights the items clinicians feel would be most crucial to include in the clinical assessment of primary care patients, a number of which have rarely been noted in the previous literature. Their importance in assessing the risk of lung or colorectal cancer will be tested as part of a large prospective cohort study (CANDID).
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Affiliation(s)
- Gemma Mansell
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele
| | - Mark Shapley
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele
| | - Danielle van der Windt
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele
| | - Tom Sanders
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele
| | - Paul Little
- Primary Medical Care, Aldermoor Health Centre, Southampton
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Bishop A, Wynne-Jones G, Lawton SA, van der Windt D, Main C, Sowden G, Burton AK, Lewis M, Jowett S, Sanders T, Hay EM, Foster NE. 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). BMC Musculoskelet Disord 2014; 15:232. [PMID: 25012813 PMCID: PMC4114128 DOI: 10.1186/1471-2474-15-232] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 06/23/2014] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Annette Bishop
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK.
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Wynne-Jones G, van der Windt D, Ong BN, Bishop A, Cowen J, Artus M, Sanders T. Perceptions of health professionals towards the management of back pain in the context of work: a qualitative study. BMC Musculoskelet Disord 2014; 15:210. [PMID: 24941952 PMCID: PMC4073509 DOI: 10.1186/1471-2474-15-210] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 06/12/2014] [Indexed: 12/01/2022] Open
Abstract
Background Musculoskeletal complaints have a significant impact on work in terms of reduced productivity, sickness absence and long term incapacity for work. This study sought to explore GPs’ and physiotherapists’ perceptions of sickness certification in patients with musculoskeletal problems. Methods Eleven (11) GPs were sampled from an existing general practice survey, and six (6) physiotherapists were selected randomly using ‘snowball’ sampling techniques, through established contacts in local physiotherapy departments. Semi-structured qualitative interviews were conducted with respondents lasting up to 30 minutes. The interviews were audio recorded and transcribed verbatim, following which they were coded using N-Vivo qualitative software and analysed thematically using the constant comparative methodology, where themes were identified and contrasted between and within both groups of respondents. Results Three themes were identified from the analysis: 1) Approaches to evaluating patients’ work problems 2) Perceived ability to manage ‘work and pain’, and 3) Policies and penalties in the work-place. First, physiotherapists routinely asked patients about their job and work difficulties using a structured (protocol-driven) approach, whilst GPs rarely used such structured measures and were less likely to enquire about patients’ work situation. Second, return to work assessments revealed a tension between GPs’ gatekeeper and patient advocacy roles, often resolved in favour of patients’ concerns and needs. Some physiotherapists perceived that GPs’ decisions could be influenced by patients’ demand for a sick certificate and their close relationship with patients made them vulnerable to manipulation. Third, the workplace was considered to be a specific source of strain for patients acting as a barrier to work resumption, and over which GPs and physiotherapists could exercise only limited control. Conclusion We conclude that healthcare professionals need to take account of patients’ work difficulties, their own perceived ability to offer effective guidance, and consider the ‘receptivity’ of employment contexts to patients’ work problems, in order to ensure a smooth transition back to work.
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Affiliation(s)
| | | | | | | | | | | | - Tom Sanders
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Staffordshire ST55BG, UK.
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Hill JC, Thomas E, Hill S, Foster NE, Rimmer Y, Shufflebotham J, Doyle C, Larkin T, van der Windt D. 57. Development and Validation of a Musculoskeletal Patient Reported Outcome Measure. Rheumatology (Oxford) 2014. [DOI: 10.1093/rheumatology/keu098.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Roddy E, Zwierska I, Hay EM, Jowett S, Lewis M, Stevenson K, van der Windt D, Foster NE. Subacromial impingement syndrome and pain: protocol for a randomised controlled trial of exercise and corticosteroid injection (the SUPPORT trial). BMC Musculoskelet Disord 2014; 15:81. [PMID: 24625273 PMCID: PMC3995668 DOI: 10.1186/1471-2474-15-81] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 03/10/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND 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. DISCUSSION This protocol paper presents detail of the rationale, design, methods and operational aspects of the SUPPORT trial. TRIAL REGISTRATION Current controlled trials ISRCTN42399123.
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Affiliation(s)
- Edward Roddy
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK
- Staffordshire Rheumatology Centre, Haywood Hospital, High Lane, Burslem, Stoke-on-Trent ST6 7AG, UK
| | - Irena Zwierska
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK
| | - Elaine M Hay
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK
- Staffordshire Rheumatology Centre, Haywood Hospital, High Lane, Burslem, Stoke-on-Trent ST6 7AG, UK
| | - Sue Jowett
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK
| | - Martyn Lewis
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK
| | - Kay Stevenson
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK
- Staffordshire Rheumatology Centre, Haywood Hospital, High Lane, Burslem, Stoke-on-Trent ST6 7AG, UK
- Physiotherapy Department, University Hospital of North Staffordshire, Stoke-on-Trent, UK
| | - Danielle van der Windt
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK
| | - Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK
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Artus M, van der Windt D, Jordan KP, Croft PR. The clinical course of low back pain: a meta-analysis comparing outcomes in randomised clinical trials (RCTs) and observational studies. BMC Musculoskelet Disord 2014; 15:68. [PMID: 24607083 PMCID: PMC4007531 DOI: 10.1186/1471-2474-15-68] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 02/25/2014] [Indexed: 02/07/2024] Open
Abstract
Background Evidence suggests that the course of low back pain (LBP) symptoms in randomised clinical trials (RCTs) follows a pattern of large improvement regardless of the type of treatment. A similar pattern was independently observed in observational studies. However, there is an assumption that the clinical course of symptoms is particularly influenced in RCTs by mere participation in the trials. To test this assumption, the aim of our study was to compare the course of LBP in RCTs and observational studies. Methods Source of studies CENTRAL database for RCTs and MEDLINE, CINAHL, EMBASE and hand search of systematic reviews for cohort studies. Studies include individuals aged 18 or over, and concern non-specific LBP. Trials had to concern primary care treatments. Data were extracted on pain intensity. Meta-regression analysis was used to compare the pooled within-group change in pain in RCTs with that in cohort studies calculated as the standardised mean change (SMC). Results 70 RCTs and 19 cohort studies were included, out of 1134 and 653 identified respectively. LBP symptoms followed a similar course in RCTs and cohort studies: a rapid improvement in the first 6 weeks followed by a smaller further improvement until 52 weeks. There was no statistically significant difference in pooled SMC between RCTs and cohort studies at any time point:- 6 weeks: RCTs: SMC 1.0 (95% CI 0.9 to 1.0) and cohorts 1.2 (0.7to 1.7); 13 weeks: RCTs 1.2 (1.1 to 1.3) and cohorts 1.0 (0.8 to 1.3); 27 weeks: RCTs 1.1 (1.0 to 1.2) and cohorts 1.2 (0.8 to 1.7); 52 weeks: RCTs 0.9 (0.8 to 1.0) and cohorts 1.1 (0.8 to 1.6). Conclusions The clinical course of LBP symptoms followed a pattern that was similar in RCTs and cohort observational studies. In addition to a shared ‘natural history’, enrolment of LBP patients in clinical studies is likely to provoke responses that reflect the nonspecific effects of seeking and receiving care, independent of the study design.
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Affiliation(s)
- Majid Artus
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK.
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Wynne-Jones G, Cowen J, Jordan JL, Uthman O, Main CJ, Glozier N, van der Windt D. Absence from work and return to work in people with back pain: a systematic review and meta-analysis. Occup Environ Med 2013; 71:448-56. [PMID: 24186944 PMCID: PMC4033140 DOI: 10.1136/oemed-2013-101571] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background A considerable proportion of work absence is attributed to back pain, however prospective studies in working populations with back pain are variable in setting and design, and a quantitative summary of current evidence is lacking. Objective To investigate the extent to which differences in setting, country, sampling procedures and methods for data collection are responsible for variation in estimates of work absence and return to work. Methods Systematic searches of seven bibliographic databases. Inclusion criteria were: adults in paid employment, with back pain, work absence or return to work during follow-up had been reported. Random effects meta-analysis and meta-regression analysis was carried out to provide summary estimates of work absence and return to work rates. Results 45 studies were identified for inclusion in the review; 34 were included in the meta-analysis. The pooled estimate for the occurrence of work absence in workers with back pain was 15.5% (95% CI 9.8% to 23.6%, n=17 studies, I2 98.1%) in studies with follow-up periods of ≤6 months. The pooled estimate for the proportion of people with back pain returning to work was 68.2% (95% CI 54.8% to 79.1%, n=13, I2 99.2%), 85.6% (95% CI 78.2% to 90.7%, n=13, I2 98.7%) and 93.3% (95% CI 84.0% to 94.7%, n=10, I2 99%), at 1 month, 1–6 months and ≥6 months, respectively. Differences in setting, risk of participation bias and method of assessing work absence explained some of the heterogeneity. Conclusions Pooled estimates suggest high return to work rates, with wide variation in estimates of return to work only partly explained by a priori defined study-level variables. The estimated 32% not back at work at 1 month are at a crucial point for intervention to prevent long term work absence.
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Affiliation(s)
- Gwenllian Wynne-Jones
- Department of Primary Care Sciences, Arthritis Research UK National Primary Care Centre, Keele University, Keele, UK
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Marshall M, Nicholls E, Kwok WY, Peat G, Kloppenburg M, van der Windt D, Myers H, Dziedzic K. Erosive osteoarthritis: a more severe form of radiographic hand osteoarthritis rather than a distinct entity? Ann Rheum Dis 2013; 74:136-41. [PMID: 24095935 PMCID: PMC4283656 DOI: 10.1136/annrheumdis-2013-203948] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objectives To determine whether erosive osteoarthritis shares the same pattern of joint involvement and risk profile as increasing grades of non-erosive hand osteoarthritis. Methods Participants were from two population-based cohorts, aged ≥50 years, reporting hand symptoms in the previous month. Interphalangeal joints were assessed for erosive osteoarthritis (Verbruggen–Veys erosive or remodelled phase) and radiographic osteoarthritis (sliding cut-offs of K&L≥2, K&L≥3 and K&L=4). At the joint level, similarities in the frequency and pattern of erosive and non-erosive osteoarthritis were assessed by Spearman's rank correlation coefficients and generalised estimating equations. At the person level, individuals with erosive osteoarthritis were compared to those with non-erosive osteoarthritis using logistic regression, adjusted for age and gender (aOR), for the following exposures: family history, previous injury, overuse and metabolic factors (BMI, dyslipidaemia, hypertension, diabetes). Results In 1076 symptomatic participants the ranked frequency of involvement for erosive joints was comparable to joints with K&L≥3 and K&L=4 (r>0.95). Patterns of joint involvement in erosive osteoarthritis were strongest for symmetry (aOR=6.5; 95% CI 3.0 to 14.1), followed by row (2.0; 0.8 to 5.0) and ray (0.3; 0.0 to 2.5), which was similar to joints with K&L≥3 and K&L=4. Individuals with erosive osteoarthritis (n=80) had an increased risk of metabolic syndrome (2.7; 1.0 to 7.1), notably dyslipidaemia (4.7; 2.1 to 10.6) compared with non-erosive osteoarthritis classed K&L≥3 (n=193). Conclusions The similar frequency of radiographic joint involvement and patterning in erosive osteoarthritis and more severe non-erosive osteoarthritis is consistent with prevalent erosive osteoarthritis being a severe form of hand osteoarthritis rather than a distinct entity. Metabolic exposures, dyslipidaemia in particular, may be implicated in erosive osteoarthritis.
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Affiliation(s)
- Michelle Marshall
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Staffordshire, UK
| | - Elaine Nicholls
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Staffordshire, UK
| | - Wing-Yee Kwok
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - George Peat
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Staffordshire, UK
| | - Margreet Kloppenburg
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Danielle van der Windt
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Staffordshire, UK
| | - Helen Myers
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Staffordshire, UK
| | - Krysia Dziedzic
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Staffordshire, UK
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van der Windt D, Croft P. From the particular to the universal – how does an efficacy trial translate to practice? Pain 2011; 152:967-968. [DOI: 10.1016/j.pain.2011.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 02/19/2011] [Accepted: 03/04/2011] [Indexed: 10/18/2022]
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Marshall M, van der Windt D, Nicholls E, Myers H, Dziedzic K. Radiographic thumb osteoarthritis: frequency, patterns and associations with pain and clinical assessment findings in a community-dwelling population. Rheumatology (Oxford) 2010; 50:735-9. [PMID: 21134961 PMCID: PMC3060622 DOI: 10.1093/rheumatology/keq371] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES The aim of this study was to investigate: (i) the frequency and patterns of radiographic OA (ROA) in the thumb joints; and (ii) associations between thumb ROA and the clinical characteristics of thumb OA in older adults with hand pain or problems. METHODS Participants were 592 community-dwelling older adults with hand pain or hand problems who attended a research clinic. Hand X-rays were taken and 32 joints were scored for the presence of ROA. The occurrence and pattern of ROA in the hand were examined. Univariable and multivariable associations of thumb pain and clinical assessments (nodes, deformity, enlargement, thenar muscle wasting, grind test, Kapandji index, Finkelstein's test and thumb extension) with ROA were investigated. RESULTS The first CMC and thumb IP joints were the hand joints most frequently affected with ROA. The thumb (thumb IP, first MCP, first CMC, trapezioscaphoid) was the most commonly affected joint group (n = 412). Isolated thumb ROA occurred more frequently than in any other isolated joint group. Multivariable analyses showed that older age, thumb pain, thenar muscle wasting and presence of nodes, deformity or enlargement best determined the presence of thumb ROA. CONCLUSION The first CMC and thumb IP joints were frequently affected with ROA. Prevalence estimates of ROA would be underestimated if these were not scored. One-third of the individuals with thumb ROA did not have involvement of the first CMC joint. The presence of thumb ROA was strongly associated with a combination of older age, thumb pain and clinical features of OA.
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Affiliation(s)
- Michelle Marshall
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire ST5 5BG, UK.
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van der Windt D, Croft P, Penninx B. Neck and upper limb pain: more pain is associated with psychological distress and consultation rate in primary care. J Rheumatol 2002; 29:564-9. [PMID: 11908574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVE To investigate the association between the extent of pain and the severity of psychological distress in neck and upper limb pain, and to establish whether extent of pain is associated with consultation frequency in primary care. METHODS The study population was selected from responders to a general health survey conducted in a general practice in North Staffordshire, UK. Responders indicating pain in the neck or upper limb area were included. The survey included the Hospital Anxiety and Depression Scale (HADS). Consultation data were retrieved for a period of 12 months following the survey. RESULTS A total of 867 responders had experienced neck-upper limb pain in the month preceding the survey (33% of all responders). Responders with more generalized pain within the neck-upper limb area had significantly higher HADS scores compared to responders with pain in one area only, particularly for depression (median scores 5 vs 3 points). Annual consultation frequency was also higher among responders with generalized pain [adjusted OR for high consultation frequency (> or = 7 visits vs 0-2 visits) 1.6, 95% CI 1.1 to 2.4]. When the analysis was restricted to consultations specifically related to neck-upper limb pain, the association between extent of pain and consultation frequency was weak and not statistically significant. CONCLUSION Our survey revealed a significant association between extent of pain in the neck-upper limb area and psychological distress, although scores for anxiety and depression were generally low, with only a small proportion of responders reporting moderate or severe symptoms. Responders with both generalized pain and depressive symptoms were more likely to consult their family doctor, but not specifically for musculoskeletal pain. These results confirm the hypothesis that general psychological well being rather than specific somatic symptoms predict consultation frequency.
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Affiliation(s)
- Danielle van der Windt
- Institute for Research in Extramural Medicine Department of General Practice, VU University Medical Center, Amsterdam, The Netherlands.
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