Published: 18 November 2019
NIHR Programme Grants for Applied Research (PGfAR) funds collaborative, multidisciplinary programmes of applied research to solve health and social care challenges.
Understanding persistent shoulder pain
Since my PhD I’ve been interested in the diagnosis, prognosis and management of shoulder pain. I knew from my doctorate that while many people with shoulder pain recover quickly, about 4 in 10 will still have pain and problems with shoulder function 6-12 months after visiting their GP. We don’t really know which patients are likely to develop persistent pain.
As a postdoc I’d worked on developing prognostic models for predicting persistent pain and work absence. This research highlighted the fact that psychological factors and co-existing neck pain could help predict outcomes for patients with shoulder pain. But the models we were using weren’t yet suitable for the clinic.
While I was working on these areas of research (between 2000 and 2010), the rate of the most commonly performed surgery for shoulder pain increased more than 7-fold in the UK, despite increasing evidence that surgery does not show better outcomes compared to sham surgery or non-surgical treatments. And at the same time, imaging such as ultrasound scans became more widely available, with only limited evidence for its effectiveness in predicting outcome or supporting referral or treatment decisions.
Applying for joint funding from NIHR and Versus Arthritis
As a methodologist (trained in epidemiology), I’d been involved in a wide range of research studies in various clinical topic areas over the years, but I was keen to get back to the many questions that need to be addressed in shoulder pain.
My aim was to develop and evaluate a better approach to assessing the likely cause and future outcome of shoulder problems, so that clinicians can offer optimal treatments matched to patients’ characteristics. To do this, I put together a proposal for a programme of research on using optimal diagnostic and prognostic information to target treatment for patients with shoulder pain - the PANDA-S study.
The first submission of PANDA-S to NIHR Programme Grants for Applied Research in 2015, focusing on a prospective cohort study to investigate the predictive value and clinical utility of diagnostic and prognostic information, was not successful. Seeking co-funding by Versus Arthritis and the NIHR was suggested as a solution by the NIHR PGfAR Programme Director (at the time Professor Paul Little). The co-funding would allow us to request the required additional time and funding to include a trial investigating the clinical and cost effectiveness of the stratified model of care we proposed for shoulder pain.
The second proposal was successful in securing joint funding from the NIHR and Versus Arthritis. The additional funds provided by Versus Arthritis allowed us to purchase ultrasound scanners, appoint staff for our research clinics, and appoint researchers with expertise in systematic reviews and qualitative research methods.
Running the research programme
The PANDA-S team is a large, multidisciplinary team of clinicians (from physiotherapy, general practice, orthopaedics, rheumatology, health psychology), methodologists (epidemiology, statistics, trials, social science) and clinical trials unit staff (trial management and study coordination, database design, administration) from Keele and Oxford.
We collaborate with partner investigators from three other Universities and with the NIHR Local Clinical Research Networks (LCRNs) in the Midlands and Thames Valley.
It is a large team of very talented people, and a considerable number of team members have progressed their careers while working on PANDA-S and moved on to new roles. This can be challenging for the team, but also offers opportunities for others.
For me as a methodologist, I have been involved in, and have led, a large number of cohort studies and trials. But leading a large team and conducting a complex programme of research in an increasingly challenging research environment and difficult time for the NHS has certainly been a big learning experience for me, which will shape me as a research leader.
We hope the results of PANDA-S can benefit patients and the NHS by:
- improving information and advice for patients about the possible causes and best ways to assess and treat shoulder pain
- supporting clinicians to better advise patients which treatment is best for them
- improving targeting of treatment options, and reducing unnecessary investigations and treatments in those who don’t need them
- reducing long-term pain, disability, and work loss due to shoulder pain in those at high risk of persistent shoulder pain.
The benefits of the NIHR-charity partnership
The partnership of NIHR with Versus Arthritis is incredibly important to raise the profile of research into musculoskeletal conditions, such as back pain, shoulder pain, osteoarthritis, and inflammatory arthritis. These conditions are leading causes globally of years lived with disability, but do not attract the same amount of funding as other long-term conditions (e.g. cardiovascular disease or cancer). The NIHR-Versus Arthritis partnership gives researchers in this field the opportunity to develop high quality, comprehensive research projects aiming to reduce the impact of chronic pain and arthritis in individuals, their families and society.
PANDA-S is now in its second year. We are in the process of analysing 24 datasets with the aim to identify characteristics of patients who are likely to benefit from common primary care treatments for shoulder pain such as exercise, shoulder injections or surgery.
Recruitment for our prospective cohort study started gradually in spring, and we are still in the process of setting up recruitment sites. We are recruiting patients with shoulder pain and following them through their care, including a clinical assessment at inclusion and gathering information on their outcomes through questionnaires.
Setting up the study in multiple regions has taken more time than planned, and response rates have been lower than expected, but we are putting a range of measures in place to increase recruitment rates. We hope to achieve our target of 1000 participants in 2020, and start development of the planned stratified care trial in 2021. This final stage of the research programme will involve around 500 patients and will test whether using more personalised care leads to better outcomes and better use of NHS resources.