Shoulder acute pain in primary healthcare: is retraining effective for GP principals SAPPHIREa randomized controlled trial

Objective. To address the question whether general practitioners (GPs) should receive practical training in shoulder problems and to test whether cortisone injections are better than anaesthetic injections for rotator cuff problems. Methods. A pragmatic split-plot, randomized trial with a cluster factorial design, conducted in general practices across five centres across the United Kingdom. Ninety-one practices were randomized to receive additional training in diagnosing and injecting rotator cuff problems or no additional training. Two hundred patients consulting their general practices with shoulder pain were then randomized to receive either a corticosteroid or lignocaine injection. The main outcome was score on the British Shoulder Disability Questionnaire (BSDQ). The Short-Form 36-item Health Survey and EuroQol at 12 months from entry to the trial were also scored. Results. Over the course of the trial there was a mean difference of 0.94 (s.e = 1.01) on the BSDQ score between the groups, with patients treated by the untrained group having a mean of 9.46 (s.e = 0.82) and those by the trained group having a mean of 8.51 (s.e = 0.60). There were no statistically significant differences between the groups. Analysing by substance injected, there was a mean difference of 0.15 (s.e = 0.48) throughout the trial between the groups, with patients given the cortisone having a mean BSDQ of 9.67 (s.e = 0.39) and those given lignocaine, 9.82 (s.e = 0.39). This was not statistically significantly different. Conclusions. Training GPs in the diagnosis and treatment of shoulder disorders does not make any difference to the outcome, in terms of pain and disability, 1 yr later. Further, there is no advantage to injecting steroid in a group with predominant rotator cuff disorder. Trial registration. International Standard Randomized Controlled Trial Number 58537244. Trial steering committee comprised Prof. Paul Dieppe, Prof. Elaine Hay, Dr Brian Hazleman and Dr Kerenza Hood.