Living with frozen shoulder. 'Here are the risks. I want the injection'. An interpretative phenomenological analysis.

BACKGROUND: Frozen shoulder is a disabling condition characterised by severe pain and loss of shoulder movement and may affect up to 5% of the population. Qualitative research documents debilitating pain and how treatment to reduce pain is a priority for people diagnosed with frozen shoulder. Corticosteroid injections are a principal treatment to reduce the pain of frozen shoulder, however little is known about the patient experience. OBJECTIVES: This study aims to address this gap in the knowledge by exploring the lived experience of people with frozen shoulder who have undergone an injection and to highlight other novel findings. DESIGN: This is a qualitative study using interpretative phenomenological analysis. One-to-one, semi-structured interviews were conducted with seven people diagnosed with frozen shoulder who had received a corticosteroid injection as part of their management. METHODOLOGY: A purposive sample of participants were interviewed via MSTeams™ due to Covid-19 restrictions. Data was collected through semi-structured interviews and analysed in accordance with interpretive phenomenological analysis methods. RESULTS: Three group experiential themes were identified: the dilemma surrounding injections; the challenges of understanding the causes of frozen shoulder; the impact on self and others. CONCLUSION: Participants conveyed a strong desire in seeking a corticosteroid injection whilst seemingly dismissing the risks. A novel concept was illuminated as frozen shoulder seemed inextricably linked with the ageing process, which negatively impacted body-image. The impact on others is driven by a sense of the unfamiliar nature of illness and it is incumbent on healthcare professionals to seek opportunities to explore the individual's beliefs.

How effective are physiotherapy interventions in treating people with sciatica? A systematic review and meta-analysis.

PURPOSE: Physiotherapy interventions are prescribed as first-line treatment for people with sciatica; however, their effectiveness remains controversial. The purpose of this systematic review was to establish the short-, medium- and long-term effectiveness of physiotherapy interventions compared to control interventions for people with clinically diagnosed sciatica. METHODS: This systematic review was registered on PROSPERO CRD42018103900. Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL (EBSCO), Embase, PEDro, PubMed, Scopus and grey literature were searched from inception to January 2021 without language restrictions. Inclusion criteria were randomised controlled trials evaluating physiotherapy interventions compared to a control intervention in people with clinical or imaging diagnosis of sciatica. Primary outcome measures were pain and disability. Study selection and data extraction were performed by two independent reviewers with consensus reached by discussion or third-party arbitration if required. Risk of bias was assessed independently by two reviewers using the Cochrane Risk of Bias tool with third-party consensus if required. Meta-analyses and sensitivity analyses were performed with random effects models using Revman v5.4. Subgroup analyses were undertaken to examine the effectiveness of physiotherapy interventions compared to minimal (e.g. advice only) or substantial control interventions (e.g. surgery). RESULTS: Three thousand nine hundred and fifty eight records were identified, of which 18 trials were included, with a total number of 2699 participants. All trials had a high or unclear risk of bias. Meta-analysis of trials for the outcome of pain showed no difference in the short (SMD - 0.34 [95%CI - 1.05, 0.37] p = 0.34, I2 = 98%), medium (SMD 0.15 [95%CI - 0.09, 0.38], p = 0.22, I2 = 80%) or long term (SMD 0.09 [95%CI - 0.18, 0.36], p = 0.51, I2 = 82%). For disability there was no difference in the short (SMD - 0.00 [95%CI - 0.36, 0.35], p = 0.98, I2 = 92%, medium (SMD 0.25 [95%CI - 0.04, 0.55] p = 0.09, I2 = 87%), or long term (SMD 0.26 [95%CI - 0.16, 0.68] p = 0.22, I2 = 92%) between physiotherapy and control interventions. Subgroup analysis of studies comparing physiotherapy with minimal intervention favoured physiotherapy for pain at the long-term time points. Large confidence intervals and high heterogeneity indicate substantial uncertainly surrounding these estimates. Many trials evaluating physiotherapy intervention compared to substantial intervention did not use contemporary physiotherapy interventions. CONCLUSION: Based on currently available, mostly high risk of bias and highly heterogeneous data, there is inadequate evidence to make clinical recommendations on the effectiveness of physiotherapy interventions for people with clinically diagnosed sciatica. Future studies should aim to reduce clinical heterogeneity and to use contemporary physiotherapy interventions.

A UK survey evaluation of First Contact Practitioners' and musculoskeletal physiotherapists' confidence, recognition, and referral of suspected axial spondyloarthritis.

BACKGROUND: Axial Spondyloarthritis is an inflammatory disease associated with significant diagnostic delays. Steen et al. (2021) found inadequate consideration of axial Spondyloarthritis (axSpA) in physiotherapists back pain assessments. Since the previous survey, increased professional education on axSpA has occurred and First Contact Practitioners (FCPs), now widely established in General Practice, are key in supporting earlier recognition. OBJECTIVES: (1) To re-evaluate physiotherapists' and evaluate FCPs' awareness, knowledge, and confidence in screening for and recognising features of axSpA and criteria prompting referral to rheumatology. (2) To compare these results to previous research (Steen et al., 2021). DESIGN: As per Steen et al. (2021), an online survey was undertaken combining back pain vignettes (reflecting axSpA, non-specific low back pain [NSLBP] and radicular syndrome) and questioning on features of suspected axSpA. RESULTS: 165 surveys were analysed. Only 73% (n = 120/165) of respondents recognised the axSpA vignette compared to NSLBP 91% (n = 80/88) and radicular syndrome 88% (n = 68/77). An improvement in axSpA recognition was demonstrated compared with previous data. FCPs performed slightly better with 77% (n = 67/87) of respondents recognising the axSpA vignette. Adequate awareness of national referral guidance was evident in only 55% of 'clinical reasoning' and 6% of 'further subjective screening' responses. There was still misplaced confidence in recognising clinical features of axSpA compared to knowledge levels shown, including high importance given to inflammatory markers. CONCLUSION(S): Musculoskeletal physiotherapists demonstrate some improved knowledge and awareness of axSpA compared with previous study findings. Consideration of axSpA is still not universal in musculoskeletal physiotherapists' or FCPs' approaches to persistent back pain assessments and awareness of national referral guidance remains limited. This study highlights the continued need for professional education. Enhanced knowledge of screening and referral criteria in musculoskeletal clinical practice would support earlier diagnosis and better outcomes.

Functional cortical changes associated with shoulder instability - a systematic review.

Background: Glenohumeral joint instability is associated with structural deficits and/or alterations in sensory and motor processing; however, a proportion of patients with glenohumeral joint instability fail to respond to surgical and rehabilitative measures. This systematic review aimed to establish if functional cortical changes occur in patients with glenohumeral joint instability. Methods: AMED, CINAHL, Cochrane Central Register of Controlled Trials, Embase, Medline, PEDro, Pubmed, PsychINFO and Scopus were searched from inception to 17 March 2021. Randomised controlled trials and non-randomised trials were included and quality was appraised using the Downs and Black tool. Results: One thousand two hundred seventy-nine records were identified of which five were included in the review. All studies showed altered cortical function when comparing instability patients with healthy controls and included areas associated with higher cortical functions. Discussion: The findings of this systematic review offer some insight as to why interventions addressing peripheral pathoanatomical factors in patients with glenohumeral joint instability may fail in some cases due to functional cortical changes. However, data are of moderate to high risk of bias. Further high-quality research is required to ascertain the degree of functional cortical changes associated with the type and duration of glenohumeral joint instability.

Physiotherapists' awareness, knowledge and confidence in screening and referral of suspected axial spondyloarthritis: A survey of UK clinical practice.

BACKGROUND: Axial spondyloarthritis (axSpA) is an inflammatory disease associated with significant diagnostic delays and is commonly missed in assessments of persistent back pain. OBJECTIVE: To explore musculoskeletal physiotherapists' awareness, knowledge and confidence in screening for signs, symptoms and risk factors of suspected axSpA and criteria for rheumatology referral. DESIGN: An online UK survey was undertaken combining back pain vignettes (reflecting axSpA, non-specific back pain and radicular syndrome) and questioning on features of suspected axSpA. Recruitment utilised online professional forums and social media. Data analysis included descriptive statistics and conceptual content analysis for free text responses. RESULTS: 132 survey responses were analysed. Only 67% (88/132) of respondents identified inflammatory pathologies as a possible cause of persistent back pain. Only 60% (79/132) recognised the axSpA vignette compared to non-specific low back pain (94%) and radicular syndrome (80%). Most suspecting axSpA would refer for specialist assessment (77/79; 92%). Awareness of national referral guidance was evident in only 50% of 'clinical reasoning' and 20% of 'further subjective screening' responses. There was misplaced confidence in recognising clinical features of axSpA (≥7/10) compared to knowledge levels shown, including high importance given to inflammatory markers and human leucocyte antigen B27 (median = 8/10). CONCLUSIONS: Musculoskeletal physiotherapists may not be giving adequate consideration to axSpA in back pain assessments. Awareness of national referral guidance was also limited. Professional education on screening and referral for suspected axSpA is needed to make axSpA screening and referral criteria core knowledge in musculoskeletal clinical practice, supporting earlier diagnosis and better outcomes.

Facet joint injections for people with persistent non-specific low back pain (Facet Injection Study): a feasibility study for a randomised controlled trial.

BACKGROUND: The National Institute for Health and Care Excellence (NICE) 2009 guidelines for persistent low back pain (LBP) do not recommend the injection of therapeutic substances into the back as a treatment for LBP because of the absence of evidence for their effectiveness. This feasibility study aimed to provide a stable platform that could be used to evaluate a randomised controlled trial (RCT) on the clinical effectiveness and cost-effectiveness of intra-articular facet joint injections (FJIs) when added to normal care. OBJECTIVES: To explore the feasibility of running a RCT to test the hypothesis that, for people with suspected facet joint back pain, adding the option of intra-articular FJIs (local anaesthetic and corticosteroids) to best usual non-invasive care is clinically effective and cost-effective. DESIGN: The trial was a mixed design. The RCT pilot protocol development involved literature reviews and a consensus conference followed by a randomised pilot study with an embedded mixed-methods process evaluation. SETTING: Five NHS acute trusts in England. PARTICIPANTS: Participants were patients aged ≥ 18 years with moderately troublesome LBP present (> 6 months), who had failed previous conservative treatment and who had suspected facet joint pain. The study aimed to recruit 150 participants (approximately 30 per site). Participants were randomised sequentially by a remote service to FJIs combined with 'best usual care' (BUC) or BUC alone. INTERVENTIONS: All participants were to receive six sessions of a bespoke BUC rehabilitation package. Those randomised into the intervention arm were, in addition, given FJIs with local anaesthetic and steroids (at up to six injection sites). Randomisation occurred at the end of the first BUC session. MAIN OUTCOME MEASURES: Process and clinical outcomes. Clinical outcomes included a measurement of level of pain on a scale from 0 to 10, which was collected daily and then weekly via text messaging (or through a written diary). Questionnaire follow-up was at 3 months. RESULTS: Fifty-two stakeholders attended the consensus meeting. Agreement informed several statistical questions and three design considerations: diagnosis, the process of FJI and the BUC package and informing the design for the randomised pilot study. Recruitment started on 26 June 2015 and was terminated by the funder (as a result of poor recruitment) on 11 December 2015. In total, 26 participants were randomised. Process data illuminate some of the reasons for recruitment problems but also show that trial processes after enrolment ran smoothly. No between-group analysis was carried out. All pain-related outcomes show the expected improvement between baseline and follow-up. The mean total cost of the overall treatment package (injection £419.22 and BUC £264.00) was estimated at £683.22 per participant. This is similar to a NHS tariff cost for a course of FJIs of £686.84. LIMITATIONS: Poor recruitment was a limiting factor. CONCLUSIONS: This feasibility study achieved consensus on the main challenges in a trial of FJIs for people with persistent non-specific low back pain. FUTURE WORK: Further work is needed to test recruitment from alternative clinical situations. TRIAL REGISTRATION: EudraCT 2014-000682-50 and Current Controlled Trials ISRCTN93184143. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 30. See the NIHR Journals Library website for further project information.

Facet-joint injections for people with persistent non-specific low back pain (FIS): study protocol for a randomised controlled feasibility trial.

BACKGROUND: The role of injections of therapeutic substances into the back as treatment for low back pain is unclear. Facet joint injections are widely used despite the absence of evidence of sustained benefit. We hypothesise that facet joint injections might facilitate engagement with physiotherapist-led, best usual care (a combined physical and psychological programme) and is a clinically and cost-effective treatment for people with suspected low back pain of facet joint origin. METHODS/DESIGN: We present here the protocol for a randomised controlled feasibility trial for a main trial to test the above hypotheses. Patients referred to secondary care with persistent non-specific low back pain will be screened and invited to take part in the study. Those who meet the eligibility criteria will be invited for a physiotherapy assessment to confirm trial eligibility and for baseline data collection. All participants (n = 150) will be offered the best usual care package with physical and psychological components. Those randomised into the intervention arm (n = 75) will, in addition, receive intra-articular facet joint injections with local anaesthetic and steroids. Primary outcome data will be collected using daily and then weekly text messaging service for a pain score on a 0-10 scale. Questionnaire follow-up will be at 3, 6, and 12 months. Evaluation of trial processes and health economic analyses, including a value of information analysis, will be undertaken. The process evaluation will be mixed methods and will include the views of all stakeholders. DISCUSSION: Whilst this trial is a feasibility study it is currently one of the largest trials in this area. The outcomes will provide some evidence on the use of facet joint injections for patients with clinically diagnosed facet joint pain. TRIAL REGISTRATION: EudraCT identifier 2014-000682-50, (registered on 12 February 14). ISRCTN registry number: ISRCTN93184143 DOI 10.1186/ISRCTN93184143 (registered on 27 February 2014).

Intraarticular Facet Injections for Low Back Pain: Design Considerations, Consensus Methodology to Develop the Protocol for a Randomized Controlled Trial.

BACKGROUND: Since the publication of guidelines by the UK National Institute for Health and Care Excellence (NICE) and the American Pain Society guidelines for low back pain in 2009 there have been deep divisions in the pain treatment community about the use of therapeutic intraarticular facet joint injections. While evidence for the effectiveness or not of intraarticular facet joint injections remains sparse, uncertainty will remain. The Warwick feasibility study, along with a concurrent study with a different design led by another group, aims to provide a stable platform from which the effectiveness and cost effectiveness of intraarticular facet joint injections added to normal care could be evaluated in randomized controlled trials (RCTs). OBJECTIVES: To reach consensus on key design considerations for the Warwick facet feasibility study from which the study protocol and working manuals will be developed. STUDY DESIGN: A consensus conference involving expert professionals and lay members. METHODS: Preliminary work identified 5 key design considerations for deliberation at our consensus conference. Three concerned patient assessment and treatment: diagnosis of possible facet joint pain, interaarticular facet joint injection technique, and best usual care. Two concerned trial analysis: a priori sub-groups and minimally important difference and are reported elsewhere. We did systematic evidence reviews of the design considerations and summarized the evidence. Our design questions and evidence summaries were distributed to all delegates. This formed the basis for discussions on the day. Clinical experts in all aspects of facet joint injection from across the UK along with lay people were invited via relevant organizations. Nominal group technique was used in 15 facilitated initial small group discussions. Further discussion and ranking was undertaken in plenary. All small group and plenary results were recorded and checked and verified post conference. Where necessary participants were contacted via email to resolve outstanding issues. RESULTS: Fifty-two delegates attended the conference with lay people and all relevant professions represented. Consensus was reached on the details of how to assess patients for facet joint pain, undertake the injections, and deliver usual care. Where post conference checking of results revealed errors in calculating ranking results on the day, consensus was reached by email consultation. All but 3 delegates agreed to be associated with the outcome. LIMITATIONS: Allocating one day for discussing a wide range of topics imposed time pressure on discussion and calculation of the numerous rankings. CONCLUSIONS: Through the use of an evidence-based, systematic, inclusive, and transparent process we have established consensus from expert health professionals in the UK, with lay input, on the clinical assessment of suspected facet joint pain, interaarticular injection for facet joint pain, and best usual care for use in a feasibility study for a proposed pragmatic clinical trial of interaarticular facet joint injections. This provides a strong basis for a clinical trial that will be acceptable to the pain treatment community.

Patient satisfaction with private physiotherapy for musculoskeletal pain.

BACKGROUND: Despite emphasis on patient centred healthcare, healthcare professionals have been slow to use validated measurements of patient satisfaction in physiotherapy practice. The aim of this cross sectional survey was to measure patient satisfaction with private physiotherapy in Ireland, for patients with musculoskeletal pain, using a previously validated survey instrument. METHODS: A multidimensional patient satisfaction questionnaire 'PTOPS', which assesses patient satisfaction with outpatient physiotherapy treatment, was translated from American English to European English, and relevant demographic and global satisfaction items were included. This was then circulated to patients with musculoskeletal pain (n = 240) for anonymous completion and return to the research team. Data were analysed using the Statistical Package for the Social Sciences (SPSS, v.12). RESULTS: In total 55% (n = 131/240) of questionnaires were returned. Just over half of the respondents were male (53.4%, n = 70), with a mean age (SD) of 37.7 years (12.4), and had previous experience of physiotherapy (65.6%, n = 86). The most common site of musculoskeletal pain was spinal (51.5% n = 66). The mean (SD) number of treatments was 8.3 (8.3), at a mean total cost (SD) of 350.2 euros (322.8 euros). The 'PTOPS' questionnaire categorised and scored satisfaction items under four domains, Enhancer, Detractor, Location and Cost. The mean score (SD), optimum score, and scoring range for each domain were: 'Enhancer' 41.2 (3.8), 50, 10-50; 'Detractor' 19.4 (4.4), 10, 10-50; 'Location' 28.0 (4.1), 35, 7-35; 'Cost' 18.9 (2.8), 7, 7-35. "Overall satisfaction with physiotherapy experience" was scored on a five-point scale "excellent to poor", with a modal response of "Very Good" (42%; n = 55). CONCLUSION: This study measured patient satisfaction with private physiotherapy treatment for musculoskeletal pain in Ireland using a previously validated outcome measure and provides a template for future studies of this increasingly important topic. Results demonstrated high levels of satisfaction with all components of physiotherapy treatment, except cost, and provided valuable patient feedback regarding their physiotherapy treatment for musculoskeletal pain. Results can be used by physiotherapists to improve future patient experiences with a view to improving patient attendance and compliance with physiotherapy treatment protocols for patients with musculoskeletal pain.

Level of distress in a recurrent low back pain population referred for physical therapy.

STUDY DESIGN: Recruitment phase of a randomized clinical trial. OBJECTIVES: To review the published literature on the use of the distress risk assessment method in different back pain populations and healthcare settings and compare results with those obtained from the current trial. SUMMARY OF BACKGROUND: Psychological distress in low back pain is commonplace, and distress increases the relative risk of poor outcome with physical treatment alone. The Distress and Risk Assessment Method is a tool for use in the clinical setting to assist in the identification of distress and clinical decision-making. METHODS: The Distress Risk Assessment Method and Roland Morris Disability Questionnaire were used to assess eligibility of patients with recurrent low back pain for recruitment into a randomized clinical trial examining different physical therapy approaches. RESULTS: In total, 221 patients were assessed, resulting in 212 correctly complete questionnaires. Of those 212, 71 (33%) showed evidence of marked distress (41 depressed and 30 somatic). Functional disability, measured using the Roland Morris Disability Questionnaire, was higher for the distressed group (mean 14.1, SD 4.8, range 3-23) than the nondistressed group (mean 8.0, SD 5.1, range 0-21). Distress and anxiety measured using the distress risk assessment method were correlated to self-reported back-related functional disability. CONCLUSIONS: Distress associated with low back pain is common with one third of patients referred for physical therapy at the units studied exhibiting a level of distress that increased their relative risk of poor outcome by 3 to 4 times. Clinically, screening this group of patients may help indicate when liaison with other professionals is appropriate and possibly identify those patients who may be too distressed to respond to physical therapy intervention alone.