title: Increasing Capacity for the Treatment of Common Musculoskeletal Problems: A Non-Inferiority RCT and Economic Analysis of Corticosteroid Injection for Shoulder Pain Comparing a Physiotherapist and Orthopaedic Surgeon.
abstract: BACKGROUND
  Role substitution is a strategy employed to assist health services manage the growing demand for musculoskeletal care. Corticosteroid injection is a common treatment in this population but the efficacy of its prescription and delivery by physiotherapists has not been established against orthopaedic standards. This paper investigates whether corticosteroid injection given by a physiotherapist for shoulder pain is as clinically and cost effective as that from an orthopaedic surgeon.
  
  
  METHODS
  A double blind non-inferiority randomized controlled trial was conducted in an Australian public hospital orthopaedic outpatient service, from January 2013 to June 2014. Adults with a General Practitioner referral to Orthopaedics for shoulder pain received subacromial corticosteroid and local anaesthetic injection prescribed and delivered independently by a physiotherapist or a consultant orthopaedic surgeon. The main outcome measure was total Shoulder Pain and Disability Index (SPADI) score at baseline, six and 12 weeks, applying a non-inferiority margin of 15 points. Secondary outcomes tested for superiority included pain, shoulder movement, perceived improvement, adverse events, satisfaction, quality of life and costs.
  
  
  RESULTS
  278 participants were independently assessed by the physiotherapist and the orthopaedic surgeon, with 64 randomised (physiotherapist 33, orthopaedic surgeon 31). There were no significant differences in baseline characteristics between groups. Non-inferiority of injection by the physiotherapist was declared from total SPADI scores at 6 and 12 weeks (upper limit of the 95% one-sided confidence interval 13.34 and 7.17 at 6 and 12 weeks, respectively). There were no statistically significant differences between groups on any outcome measures at 6 or 12 weeks. From the perspective of the health funder, the physiotherapist was less expensive.
  
  
  CONCLUSIONS
  Corticosteroid injection for shoulder pain, provided by a suitably qualified physiotherapist is at least as clinically effective, and less expensive, compared with similar care delivered by an orthopaedic surgeon. Policy makers and service providers should consider implementing this model of care.
  
  
  BACKGROUND
  Australia and New Zealand Clinical Trials Registry 12612000532808.
authors.affiliation: Gold Cost Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, 4215, Gold Coast, Australia.|Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, QLD 4222, Gold Coast, Australia.
authors.forename: Darryn
authors.identifier: http://orcid.org/0000-0002-8884-8596
authors.initials: D
authors.lastname: Marks
authors.affiliation: Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, QLD 4222, Gold Coast, Australia.
authors.forename: Leanne
authors.initials: L
authors.lastname: Bisset
authors.affiliation: Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, QLD 4222, Gold Coast, Australia.|Metro North Hospital and Health Service, 112 Alfred Street, Fortitude Valley, QLD 4006, Brisbane, Australia.
authors.forename: Tracy
authors.initials: T
authors.lastname: Comans
authors.affiliation: Gold Cost Hospital and Health Service, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, 4215, Gold Coast, Australia.
authors.forename: Michael
authors.initials: M
authors.lastname: Thomas
authors.affiliation: Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, QLD 4222, Gold Coast, Australia.
authors.forename: Shu Kay
authors.initials: SK
authors.lastname: Ng
authors.affiliation: School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, St Lucia, QLD 4072, Australia.|Physiotherapy Department, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD 4006, Australia.
authors.forename: Shaun
authors.initials: S
authors.lastname: O'Leary
authors.affiliation: Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, & NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, LS7 4SA, United Kingdom.
authors.forename: Philip G
authors.initials: PG
authors.lastname: Conaghan
authors.affiliation: Menzies Health Institute Queensland, Griffith University, Parklands Drive, Southport, QLD 4222, Gold Coast, Australia.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Scuffham
mesh_terms: D004311:Double-Blind Method; D006801:Humans; D009140:Musculoskeletal Diseases / Q000628:therapy*; D000072161:Orthopedic Surgeons; D059825:Physical Therapists; D026741:Physical Therapy Modalities; D020069:Shoulder Pain / Q000628:therapy*