Purpose
GTPS is challenging and difficult to diagnose and treat. It has a prevalence 10-25 % of the general population and effects one in four woman over 50. Anecdotally there is variation in how this condition is managed. Clinicians want to provide evidence based care to help inform patients in their decision making. For this reason, a service evaluation was carried out to explore what treatment was currently being offered in our service and a literacy search and appraisal on the latest evidence. Findings have influence pathway design for management of GTPS.
APP in spinal clinics injected 69% of patients
APP in MSK clinics injected 46% of patients
Approach
Part One:
Service evaluation and audit was carried out on patients (n=92) presenting to a large musculoskeletal interface service between 2017-2018 and clinically diagnosed with GTPS. The audit explored treatments offered by different professional groups, eg Rheumatology, advance physiotherapist in musculoskeletal and spinal clinics and GP's.
Part two:
Critically appraised topic (CAT), PICO developed and key word search of the literature between 2009-2018 looking for systematic reviews and randomised control trial. Articles appraised using appraisal tool (CASP) and a clinical bottom line was generated from the best available evidence. Specific question was: In adults with greater trochanteric pain syndrome (GTPS) is an injection of local anaesthetic and corticosteroid equally clinically and cost effective at reducing pain and improving function than a physiotherapy led exercise regime?
Outcomes
Results:
Part One Service evaluation:
n=92 identified variation in treatment delivered to patients with GTPS Variation in treatment received with 58% of patients receiving an injection, 35 % referred to physiotherapy 7% receiving advice. There was variation between clinicians with Rheumatologist / GPSI injecting 74% of patients, 16% referred to physiotherapy and 10% received advice. Advanced physiotherapists in spinal clinics injected 69% of patients, referred 28% to physiotherapy and 3% had advice. Advanced physiotherapists in musculoskeletal clinics injected 46% of patients, referred 47% to physiotherapy and 7% received advice.
Part two Key findings from CAT:
The best evidence identified through this process was by Mellor et al (2018). They carried out a good quality randomised control trial on patients with GTPS for more than 3 months and found that education plus exercise delivered by a physiotherapist involving a tendon loaded program had better global rating of change (GROC) at 8 and 52 weeks compared to corticosteroid injection and wait and see. Therefore patients who have GTPS should receive a tendon loaded exercise programme delivered by a physiotherapists involving education as a first line of treatment.
Conclusion(s): We identified clinical inconsistency in the management of GTPS. Good quality research should be used to inform clinical practice and shared decision making. Good quality evidence needs to be mobilised into practice to inform pathways which will ensure clinical consistency and make best use of scarce resources. Patients with GTPS should be offered good quality education and a tendon loaded exercise program by a physiotherapist as first line of treatment.
Cost and savings
No further data
Implications
Impact of this work has been shared locally and there has been pathway redesign. There are plans to share this process with other CAT groups and our local physiotherapy teams.
Top three learning points
No further data
Funding acknowledgements
Not funded